Transfusion‐related adverse reactions reported to the National Healthcare Safety Network Hemovigilance Module, United States, 2010 to 2012

Transfusion - Tập 55 Số 4 - Trang 709-718 - 2015
Alexis R. Harvey1, Sridhar V. Basavaraju1, Koo‐Whang Chung1, Matthew J. Kuehnert1
1Office of Blood, Organ and Other Tissue Safety, Division of Healthcare Quality Promotion, National Center for Emerging, Zoonotic, and Infectious Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia.

Tóm tắt

Background

In 2010, health care facilities in the United States began voluntary enrollment in the National Healthcare Safety Network (NHSN) Hemovigilance Module. Participants report transfusion practices; red blood cell, platelet (PLT), plasma, and cryoprecipitate units transfused; and transfusion‐related adverse reactions and process errors to the Centers for Disease Control and Prevention through a secure, Internet‐accessible surveillance application available to transfusing facilities.

Study Design and Methods

Facilities submitting at least 1 month of transfused components data and adverse reactions from January 1, 2010, to December 31, 2012, were included in this analysis. Adverse reaction rates for transfused components, stratified by component type and collection and modification methods, were calculated.

Results

In 2010 to 2012, a total of 77 facilities reported 5136 adverse reactions among 2,144,723 components transfused (239.5/100,000). Allergic (46.8%) and febrile nonhemolytic (36.1%) reactions were most frequent; 7.2% of all reactions were severe or life‐threatening and 0.1% were fatal. PLT transfusions (421.7/100,000) had the highest adverse reaction rate.

Conclusion

Adverse transfusion reaction rates from the NHSN Hemovigilance Module in the United States are comparable to early hemovigilance reporting from other countries. Although severe reactions are infrequent, the numbers of transfusion reactions in US hospitals suggest that interventions to prevent these reactions are important for patient safety. Further investigation is needed to understand the apparent increased risk of reactions from apheresis‐derived blood components. Comprehensive evaluation, including data validation, is important to continued refinement of the module.

Từ khóa


Tài liệu tham khảo

10.1111/j.1423-0410.2010.01442.x

10.1111/j.1423-0410.2010.01366.x

10.1111/j.1365-3148.2009.00947.x

Giampaolo A, 2007, The first data from the haemovigilance system in Italy, Blood Transfus, 5, 66

10.1016/j.tmrv.2006.05.002

10.1016/j.transci.2004.07.005

10.1016/j.transci.2004.07.010

10.1046/j.1537-2995.2002.00202.x

US. Department of Health and Human Services.The 2011 national blood collection and utilization survey report. Washington DC: Department of Health and Human Services;2013.

US. Food and Drug Administration.Vaccines Blood & Biologics. Transfusion/donation fatalities.2013[cited 2013 Dec 20]. Available from:http://www.fda.gov/biologicsbloodvaccines/safetyavailability/reportaproblem/transfusiondonationfatalities/default.htm

10.21307/immunohematology-2019-253

The Joint Commission.Sentinel event policy and procedures.2013[cited 2013 Dec 20]. Available from:http://www.jointcommission.org/Sentinel_Event_Policy_and_Procedures/

US. Centers for Disease Control and Prevention.National Notifiable Diseases Surveillance System (NNDSS). Division of Health Informatics and Surveillance (DHIS) Centers for Disease Control and Prevention;2013[cited 2013 Dec 20]. Available from:http://wwwn.cdc.gov/nndss/default.aspx

Commonwealth of Massachusetts Department of Public Health Clinical Laboratory Program.Blood bank monthly activity report.2013[cited 2013 Dec 20]. Available from:http://www.mass.gov/eohhs/gov/departments/dph/programs/hcq/labs/public‐health‐clinical‐lab‐blood‐banks.html

US. Centers for Disease Control and Prevention.National Healthcare Safety Network.2013[cited 2013 Dec 20]. Available from:http://www.cdc.gov/nhsn/

US. Centers for Disease Control and Prevention.The National Healthcare Safety Network (NHSN) manual: biovigilance component v1.3. Atlanta (GA): Division of Healthcare Quality Promotion National Center for Emerging and Zoonotic Infectious Diseases Centers for Disease Control and Prevention 2011:1‐30.

PfuntnerA WierLM StocksC.Most frequent procedures performed in U.S. hospitals 2011: Statistical Brief #165 Healthcare Cost and Utilization Project (HCUP). Rockville (MD): Agency for Healthcare Research and Quality;2013.

10.1159/000118887

10.1016/j.tracli.2013.09.002

10.1111/trf.12378

10.1111/vox.12064

10.1111/j.1537-2995.2012.03752.x

10.1016/j.transci.2013.09.013

10.5858/2007-131-708-NCOBT

10.1111/j.1537-2995.2011.03247.x

10.1111/trf.12597

10.1111/trf.12498

10.1111/j.0958-7578.2004.00513.x

10.3201/eid1701.100660

10.1093/heapol/czs022

10.1001/jama.2010.1637

10.1016/j.annepidem.2007.03.013

10.1086/425000

10.1016/j.ajic.2010.05.016

10.1016/j.ajic.2013.06.014

10.1086/501563