Improving donor and patient safety. Portuguese haemovigilance system — donor adverse reactions, errors and near miss events — reports

Streszczenie

Understanding the critical points in the blood transfusion chain through reporting, monitoring and analysis of donor and transfusion adverse reactions, transfusion errors, near miss events and their (potential) consequences is essential for defining of appropriate prevention and corrective measures and is therefore crucial for improvement of donor and patient safety. The system of reporting transfusion-related adverse reactions was implemented in Portugal in 2008 however the process of notification of donor adverse reactions, blood establishment and hospital blood bank errors and near miss events was in use since 2009. As regards frequency and severity, the data concerning donor adverse reactions are consistent with data reported in medical literature and underline the safety of blood donation in Portugal. The most critical area for hospital blood bank near miss events and errors is the clinical area. In most of the cases these events are associated with patient misidentification. Correct patient identification must be considered the core clinical skill as errors due to misidentification have major impact in every field of medicine, particularly in transfusion where such errors may even be fatal. However, with effective education, training and competency assessment most of such errors and events are preventable and can be eliminated.