Update in Hemovigilance

Serious complications can arise from transfusion and a significant number of these reactions are due to preventable errors. These errors occur during all steps of the transfusion process, including patient blood sample collection, product administration, testing and storage. Hemovigilance systems help monitor reactions and can lead to implementation of safety interventions. The National Healthcare Safety Network (NHSN), which is operated by the Center for Disease Control and Prevention, established a Hemovigilance module in 2010 to better capture the frequency of transfusion-related errors. The NHSN recently released data on transfusion-related errors, adverse reactions, and blood product wastage from 2014-2022.

During this time, 356 facilities submitted data, and of these, 80 facilities reported 9,822 errors. Of those errors, 89.3% were discovered and addressed before transfusion, but still resulted in significant blood product wastage. Of the 1,042 incidents in which blood was transfused, approximately 1% resulted in an adverse reaction. The majority were febrile non-hemolytic reactions, but serious complications including transfusion-associated circulatory overload reaction, acute hemolytic transfusion reaction, and delayed hemolytic transfusion reaction were observed.

Over half (59.5%) of the transfusion-related errors occurred during either blood sample collection or handling. This finding highlights the need for transfusion services to collaborate with other departments to reduce errors that may lead to enhanced transfusion safety and less blood product wastage. 

Ortiz, J. Griffin, I. et al. Transfusion-related errors and associated adverse reactions and blood product wastage as reported to the National Healthcare Safety Network Hemovigilance Module, 2014-2022. Transfusion Vol 64, No. 4, April 2024