This report presents adverse events in the transfusion service that did not lead to clinical reactions in blood donors, or in patients who received blood, but that in other circumstances could have been harmful.
In 2020, we received 155 reports. Of these, 78 were reports of newly discovered anti-D allo-immunization in women.
Of the remaining 77 reports, 32 (42 %) were in the main process category Blood donor selection, 13 (17 %) were in the main process of Transfusion, and seven (9 %) in Blood donor testing.
Thirty-three incidents (43%) were classified as human error. In addition, Blood sample taken from the wrong person and Blood sample not labelled correctly is also human error. Hence, in total 37 incidents (48%) were human error. Twenty (26%) were classified as no error. Many of these are blood donor selection, where the donor has filled out the questionnaire, and been interviewed but still has neglected to provide important information.
In 2020, we received 16 reports of Incorrect blood component transfused but without side effects. It's about the same number as for previous years. In three of the cases, blood was given to the wrong patient, but were compatible.
Thirty-eight (49 %) of the 77 incidents were reported as detected by routine inspection/review or by alarm/warning from a computer system/equipment. It testifies to good routines in the blood banks. Nevertheless, it is stated that 20 (26 %) incidents were discovered by chance. It would have been desirable to know more about these, especially to see if detection really was accidental or if also in these incidents there were a form of routine control or review that led to the incidents being discovered.
The report contains 21 examples of adverse events. These examples describe individual events that could occur everywhere. By looking at what others have reported, one can assess whether the same can happen in one's own blood bank and take appropriate precautions.