Patient Safety Topics
:
Blood Transfusion
Overview

Transfusion is not without serious risk, ranging from mild reactions to life-threatening conditions. Transfusion-related acute lung injury, transfusion-associated circulatory overload, and hemolytic transfusion reactions represent the most common morbidity and mortality events reported nationally. Although not all transfusion-related events are caused by errors, this complex process has many critical decision points at which errors can occur; preparing and administering a transfusion is a multistep and multidisciplinary process. Pennsylvania Patient Safety Reporting System (PA-PSRS) data show staff are identifying errors and making corrections prior to the event resulting in harm to the patient. Hemovigilance surveillance programs, emerging both internationally and in the Unites States, seek to learn from both Serious Events and Incidents, to continually improve the safety of blood transfusions. Advances in donor screening; improved testing of the blood supply; use of emerging technology, such as barcoding; and improvements in transfusion medicine practices have been found to increase the safety of blood transfusion.

Key Data and Statistics

From January 1, 2010, through December 31, 2014, healthcare facilities reported 19,687 events involving a blood transfusion to the Pennsylvania Patient Safety Authority. Of these reports, 19,492 (99%) were categorized as Incidents that did not result in patient harm. A majority of the events (16,513) were reported under the category of transfusions. The American Red Cross reports that more than 30 million transfusions of blood components are performed each year in the United States. 

Of the 10 events associated with severe harm or death, only 1 event was attributed to the patient receiving the wrong blood (see Figure 1). Transfusion events occurred most frequently in patients age 70 to 79 years (18.96%, n = 3,732) followed by age 60 to 69 (18.57%, n = 3,655) and age 80 to 89 (17.55%, n = 3,456; see Figure 2). The most frequently reported event type was transfusion event (83.88%, n = 16,513) followed by an error related to procedure/treatment/test (6.66%, n = 1,312) and complication related to a procedure/treatment/test (4.36%, n = 858; see Figure 3).

Figure 1. Transfusion-Related Reports by Harm Score, 2010-2014, as Reported to the Pennsylvania Patient Safety Authority (N = 19,687)

Figure 1. Transfusion-Related Reports by Harm Score, 2010-2014, as Reported to the Pennsylvania Patient Safety Authority 

Figure 2. Transfusion-Related Reports by Age, 2010-2014, as Reported to the Pennsylvania Patient Safety Authority (N = 19,687)

Figure 2. Transfusion-Related Reports by Age, 2010-2014, as Reported to the Pennsylvania Patient Safety Authority (N = 19,687) 

Figure 3. Transfusion-Related Reports by Event Type, 2010-2014, as Reported to the Pennsylvania Patient Safety Authority (N = 19,687)

Figure 3. Transfusion-Related Reports by Event Type, 2010-2014, as Reported to the Pennsylvania Patient Safety Authority 

Educational Tools

​Transfusion Process Map
This sample diagram outlines the blood transfusion process.

Multimedia

​Visit this section in the future for any multimedia associated with this patient safety topic.

Advisory Articles

 

Safety Tips for Patients

 

 

©2018 Pennsylvania Patient Safety Authority