Abstract
This study was intended to identify strategies for preventing adverse events by analyzing incidents occurring during the 7-year period from January 2000 to December 2006. The report form included the contents, ratio of incidents to number of blood products used, place and location, person involved with the patient, and causes. In total, 101 cases were reported, giving a frequency of incidents to the total number of transfusions of 0.51%. By location, the incidents occurred in inpatient wards, laboratories, operation rooms and ICU, in ascending order of frequency. The percentage of incidents in relation to autologous blood among the total number of autologous blood collections was relatively high (1.8%). Of the 90 cases involving patients, 70% of patients were over 70 years of age and 30% had physical disorders such as delusion and dementia. The incidents were identified by nurses in most cases. By type, there were 56 cases in starting and during the use of blood products, 24 cases in handling blood, 11 cases in stocking and preparation for transfusion, 3 cases in testing and 7 other cases. These were caused by errors in identification in 48.5%. Many of the incidents in our hospital are characteristic of actions relating to autologous blood, and handling this is thought to be important.
