TRANSFUSION ERROR SURVEILLANCE SYSTEM (TESS) Report

TRANSFUSION ERROR SURVEILLANCE SYSTEM (TESS) 2012-2013 Report

TO PROMOTE AND PROTECT THE HEALTH OF CANADIANS THROUGH LEADERSHIP, PARTNERSHIP, INNOVATION AND ACTION IN PUBLIC HEALTH. Public Health Agency of Canada Également disponible en français sous le titre : Système de surveillance des erreurs transfusionnelles : Rapport 2012-2013 To obtain additional copies, please contact: Centre for Communicable Diseases and Infection Control Public Health Agency of Canada 130 Colonnade Road, A/L: 6503A Ottawa, Ontario, K1A 0K9 E-mail: ccdic-clmti@phac-aspc.gc.ca Acknowledgments: The development of the Transfusion Error Surveillance System (TESS) would not have been possible without the collaborative support and continued commitment of the many transfusion safety officers, medical laboratory technologists and other healthcare professionals in hospitals and blood Transfusion Services. Their dedication to reducing errors and increasing patient safety has led to the collection and analysis of 2012-2013 TESS data. N.B. This document must be cited as the source for any information extracted and used from it. Suggested citation: Public Health Agency of Canada. Transfusion Error Surveillance System (TESS) 2012-2013 Report. Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, 2015. This publication can be made available in alternative formats upon request. Her Majesty the Queen in Right of Canada, as represented by the Minister of Health, 2015 Publication date: July 2016 This publication may be reproduced for personal or internal use only without permission provided the source is fully acknowledged. However, multiple copy reproduction of this publication in whole or in part for purposes of resale or redistribution requires the prior written permission from the Minister of Public Works and Government Services Canada, Ottawa, Ontario K1A 0S5 or copyright.droitdauteur@pwgsc.gc.ca. Cat.: HP40-77/2014E-PDF ISBN: 978-1-100-24887-5 Pub.: 140248

Information to the reader of the Transfusion Error Surveillance System (TESS) 2012-2013 Report The Centre for Communicable Diseases and Infection Control (CCDIC) of the Public Health Agency of Canada (the Agency) is pleased to present the 2012-2013 Transfusion Error Surveillance System (TESS) Report. This report presents transfusion error surveillance data submitted during 2012 and 2013 by Canadian sentinel hospitals participating in the Transfusion Error Surveillance System (TESS). The TESS is a voluntary surveillance system established by the Agency to capture non-nominal data on errors occurring at any point in the transfusion chain, including those detected before or after transfusion of blood and blood products to the patient, as well as those that may or may not have resulted in adverse transfusion reactions. The overall goal of the TESS is to identify potential areas for improvement in the transfusion chain and, ultimately, improve transfusion and transfusion safety in Canada. CCDIC is responsible for the collection, management and analysis of the TESS data, as well as the production of reports summarizing key findings. CCDIC supports the use of these data to inform public health and policy action. In addition, CCDIC supports the Agency s ongoing commitment to improving data quality, and to defining and setting surveillance standards.

TABLE OF CONTENTS Executive summary... 1 Introduction... 3 Methods... 4 a) Definition... 4 b) Data collection... 4 c) Error coding... 5 d) Potential severity of transfusion error... 7 e) Case validation... 9 f) Statistical analysis... 9 Results 10 a) Geographical coverage of the TESS... 10 b) Reported transfusion-related errors... 11 c) Potential severity of reported transfusion-related errors... 18 d) Transfusion-related errors that did not reach the patients... 19 e) Transfusion-related errors that reached the patients (i.e. detected post transfusion)... 23 Conclusion and future work... 30 References... 31 Appendix 1: Transfusion-related errors discovered through quality assurrance review and audits of the inventory and transfusion documentation more than 2 days after the event had occurred... 32 Appendix 2: Specific event codes & corresponding descriptions... 36

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1 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT Executive summary Blood transfusions are an important component of Canada s health care system. Although Canada has one of the safest blood systems in the world, transfusion-related errors can occur at various points in the transfusion chain, which encompasses any point in the collection, labelling, testing, storing, handling, transfusion, etc. of blood components and products and during the collection, labelling, testing, storing and handling of pre-transfusion patient samples. Transfusion-related errors may occur in either clinical or laboratory settings and may result in ABO incompatibilities, administrative delays, product wastage, inappropriate transfusions and the possible need for sample re-collection. Limiting opportunities for transfusion errors is therefore an important aspect of public health safety. This report offers an analysis of the Transfusion Error Surveillance System (TESS) data reported from 2012 to 2013. Findings are presented for all transfusion-related errors, including errors that were detected prior to blood transfusion as well as errors detected during and after blood transfusion. The TESS was initiated in 2005 by the Public Health Agency of Canada (the Agency) to monitor errors occurring at any point in the transfusion chain. Currently, 15 hospitals participate in the surveillance as sentinel sites and report all transfusion-related errors to the Agency on a quarterly basis. By tracking transfusion-related errors it is possible to identify not only the the policy and procedure in the transfusion chain where errors most commonly occur, but also the points where changes can be implemented in order to ensure mechanisms are in place to detect errors before transfusion as well as to limit the likelihood for transfusion errors. Overall, a total number of 17,344 transfusion-related errors were reported from 2012 (n=8,698) to 2013 (n=8,646) and, sample collection (36.2%) and sample handling (14.4%) errors constituted the most frequently reported of all the errors. Highest occurrence rates were recorded by medical/surgical wards (22.1%), emergency rooms (20.9%), Transfusion Services (18.3%), outpatient clinics (11.0%) and intensive care units (11.4%). The robustness of the detection processes in hospitals participating in the TESS was once again demonstrated through the capturing of over 93% (n=16,193) of the errors before they reached the patients. Detection by the Transfusion Service alone accounted for 93.5% (n=15,140) of these errors also sometimes referred to as near-miss. Of the 1,151 errors that reached the patient, approximately 97% (n=1,117) caused no harm. The majority of the remaining 3% (n=34) that caused some harm to the patients were errors related to product request (n=26) and unit transfusion (n=6). These two categories of errors were linked to 22 cases of transfusion-associated circulatory overload (TACO), 6 cases of febrile non-hemolytic reactions, 3 cases of minor allergic reactions and 1 case of IVIG headache. The remaining two errors that resulted in harm to the patients were sample testing and product selection errors which were respectively linked to the development of an acute hemolytic reaction (n=1) and a delayed serologic reaction (n=1). The TESS data demonstrate that blood transfusions are both safe and efficient in Canadian hospitals participating in the surveillance coordinated by the Agency. Only 0.2% of all transfusion errors reported to the TESS network resulted in harm to patients and none of these cases resulted in death. While these findings may undoubtedly be suggestive of very efficient transfusion error detection processes/

2 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT procedures within participating hospitals, they also highlight potential areas for improvement which are the processes from which the errors that escaped detection were generated, most notably, the product request and unit transfusion processes. Similarly, hospitals should regularly revise/update safety and detection processes in place in each of its units/wards, with each unit/ward/service paying particular attention to processes related to errors for which they were the source, but not the detectors. Data collected through the TESS facilitate the identification and evaluation of preventive measures designed to optimize system efficiency and, most importantly, patient safety. For example, in one participating hospital, the TESS data facilitated the adoption of prospective auditing of all blood requests to ensure compliance with hospital transfusion guidelines for both indication and dose. This demonstrates the importance of surveillance of transfusion-related errors in Canadian hospitals providing transfusion services.

3 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT Introduction Blood transfusions are an important component of Canada s health care system. Each year in Canada, transfusion of blood and blood products, which may be used to treat blood loss following trauma or surgery or to treat people suffering from conditions such as anemia and cancer, result in improved patient health and saving lives. Although the risk of an adverse event following transfusion is low in Canada due to robust precautionary measures, transfusion-related errors can and do occur. These errors may occur at any step along the transfusion chain, from the collection of blood at donor clinics to the transfusion of blood and blood products to the patient in a hospital setting. Transfusion-related errors can therefore occur in either the laboratory or clinical settings and may arise during the collection, labelling, testing, storing, handling or transfusion of blood and blood products. These errors may result in ABO or other antigen incompatibilities, administrative delays in transfusion or procedures, product wastage, inappropriate transfusions and the possible need for sample re-collection. Ultimately, these errors have the potential to impact patient safety and to increase costs incurred by the health care system. Mitigating the risk of transfusion errors is therefore a leading priority for the government of Canada. Recognizing the importance of transfusion safety in Canada, the Public Health Agency of Canada (the Agency) developed the Transfusion Error Surveillance System (TESS) in 2005. The TESS was designed to monitor the frequency of all types of errors that can occur at any step in the transfusion chain. Initially implemented as a pilot study encompassing 11 hospitals, the TESS has evolved into a voluntary sentinel surveillance system involving 15 hospitals across 4 Canadian provinces and territories 1. The TESS data serves as a complement to data collected through the Transfusion Transmitted Injuries Surveillance System (TTISS) which monitors the incidence of adverse reactions following blood transfusion in Canada (Transfusion Transmitted Injuries Surveillance System: 2006-2012 Report). Participating hospitals provide data on a quarterly basis using a secure electronic web-based server maintained by the Agency; all data are captured anonymously to promote participation and complete reporting by all sites. In addition to data on transfusion errors, participating hospitals provide the number of blood components received, requested, prepared and issued, as well as the number of samples received and tests performed (by location of service whenever possible) for the purpose of calculating error rates. The TESS is a unique blood safety surveillance system in terms of its comprehensiveness; at present, no other surveillance system in the world collects data on all errors occurring throughout the transfusion chain regardless of their potential outcome. However, by identifying the points in the transfusion chain where errors most commonly occur, including those that are detected prior to actual blood transfusion, it is possible to target these areas through corrective action and, ultimately, increase patient safety and reduce system inefficiencies. Following the implementation of measures to minimize opportunities for transfusion errors, the TESS data may be used to determine the efficacy of said measures. Findings may also provide comparable benchmarks for hospitals in Canada regardless of whether they participate or not in the TESS although those not participating will have to adhere to the TESS protocol to ensure validity of data comparisons. The same condition will apply if international comparisons are considered. 1 Refer to www.phac-aspc.gc.ca or Transfusion Error Surveillance System: Pilot Project Report 2005-2007 for details on the development of the TESS as well as 2005-2008 pilot project findings.

4 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT Methods a) Definition Transfusion errors reported through the TESS are defined as unexpected, unplanned deviations from standard operating procedures or applicable laws and regulations, usually attributable to a human or system problem, that could: (i) adversely affect the safety, efficacy or quality of blood and blood products (plasma derivatives) as well as the safety of recipients, or/and (ii) result in inefficiencies or cost-ineffective care. b) Data collection From 2012 to 2013, data on transfusion-related errors were reported by a core group of 15 hospitals from 4 Canadian provinces/territories: six were of small transfusion capacity (less than 2,000 RBC units per year), five were of medium transfusion capacity (between 2,000 to 10,000 RBC units per year) and four were of large capacity as they transfused more than 10,000 RBC units per year. Errors are detected within participating hospitals using various methods that include ongoing systematic quality control (chart audit, record review, real-time prospective transfusion audit), scheduled quality assurance, supervisory reports and reporting by any other individual. Since scheduled quality control or supervisory reports are not standardized across the participating hospitals and, their systematic implementation could not be ascertained, errors discovered through these processes were considered for the overall analysis only if they were detected within two days following their occurrence. Those that were discovered more than two days later were analysed separately and are presented in Appendix 1. The reporting process begins with the individuals who discover the event, whether or not they were involved. Following detection of a transfusion related error at a hospital participating in the TESS, nonnominal data regarding the error are collected by the hospital site. Brief narrative of the error is used to determine the type and code to which the error correspond. This code, as well as other pieces of information such as the date, time and location of the error, the point in the transfusion chain at which the error occurred, the point in the transfusion chain at which the error was detected, and the potential/actual severity of the error and its consequences to the patient, are captured using an online reporting form. The data collected are validated and consolidated into a single file by the Provincial/Territorial Blood Coordinating Office (P/T BCO). The data elements required for the TESS are then extracted and exported to the Public Health Agency of Canada (the Agency) as per the agreement between the participating P/Ts and the Agency. Data exports occur every 3 months. A user s manual for the TESS web application was developed to assist the P/T BCO with the data transfer.

5 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT c) Error coding Transfusion-related errors captured through the TESS are classified using a limited set of predefined, standardized alpha-numeric codes described in detail in the TESS User s manual. The letters in the codes indicate the category within which the error falls (Table 2) and the numeric value differentiates specific errors within each category. For instance all errors described with DC codes are errors that occurred at the level of the distributor/supplier of blood components or blood products; whereas those with UT codes occurred at the time of transfusion: for example, a wrong product/unit transfused to a patient or a wrong patient transfused (Table 2). An example of an error code would be: error coded as a DC 02 is a processing/testing error that occurred at the distributor level, a DC 03 would be a labelling error, etc. Complete listing of the error codes is provided in Appendix 1. Error coding was introduced to enhance the surveillance capabilities as the coding reduces dependence on unstructured narratives which are not made available to the Agency for confidentiality. To ensure consistency of error coding across Provinces/Territories participating in the TESS, the Agency organises monthly error coding exercises where the P/T BCO staff and reporting sites are invited to discuss complex cases for which error coding may be difficult and may benefit from group discussions which promote standardized reporting. Also, baseline training for error coding is offered to sites aspiring to join the TESS. The transfusion chain described in Figure 1 indicates where each category of errors occurs. There are errors that occur only in laboratory settings (Transfusion Services, blood suppliers, laboratory services and service providers) or clinical settings (i.e. hospital care units where patients receive transfusion care: operating rooms, emergency rooms, out-patient clinics, intensive care units, obstetrics clinics and units, etc.). Errors related to distributor codes (DC), product check-in (PC), inventory management (IM), unit storage (US), sample receipt (SR), sample testing (ST), product selection (PS), unit manipulation (UM) and unit issue (UI) occur only in laboratory setting while those related to product request (PR), sample collection (SC), request for pick-up (RP) and unit transfusion (UT) only occur in clinical setting (figure 1).

6 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT Table 1. General error codes & corresponding denominator data 2, TESS 2012-2013 Code Error Type Description DC Distributor codes Errors occurring at the supplier level (including blood manufacturers) Errors that relate to putting products into inventory PC Product check-in from the Blood Centre, another site/campus or return from the ward. US Unit storage Errors related to incorrect storage of blood products/components within the Transfusion Services IM Inventory Errors related to inventory management Management PR Product request Errors related to placing an order/request for a product SC Sample collection Errors that relate to collecting or labelling specimen tubes Events related to test ordering, sample collection and SH Sample handling transportation that do not involve the sample itself. Errors related to managing requisition, Sample transport errors, etc. Corresponding denominator Units of product received Units of product requested Samples received SR Sample receipt Errors related to receipt of samples in the laboratory ST Sample testing Testing errors Tests performed PS Product selection Production selection errors UM Unit manipulation Processing errors (pooling, irradiation, ) RP Request for pick-up Errors related to picking up blood products/ components for transfusion Events occurring during the issue of blood or blood UI Unit issued product for transfusion. Wrong product issued, Product issued to wrong patient, etc. Events occurring outside of the Transfusion Services involving the storage, selection and administration of UT Unit transfusion a blood or blood product. Wrong product administered, Product administered to wrong patient, etc. MS Miscellaneous Errors not related to any of those listed above (e.g. incomplete/ incorrect patient registration, ) Units of product prepared Units of product issued - 2 Denominator data used for the calculation of the rate of occurrence of transfusion errors

7 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT d) Potential severity of transfusion error The potential severity is a measure of the harm that the error may cause to the patient if the error is not detected. High severity level is assigned to errors that have potential to cause serious injury (including fatal outcome), whereas low and medium severity levels are assigned to errors with potential to cause no or minor/transient injury, respectively. The national TESS working group identified errors that by definition are listed in Table 2 as errors of potential high severity. Table 2: Pre-defined high (potential) severity errors, TESS 2012-2013 Type of error Description Error code Product request Order for wrong patient PR 01 Sample labelled with wrong patient identification SC 01 Sample collection Not labelled SC 02 Wrong patient collected (not from intended patient) SC 03 Label incomplete/illegible for key patient identifiers (e.g., SC 07 name, identification, birthdate) Armband incorrect/not available SC 10 Sample handling Paperwork and sample ID do not match SH 02 Sample receipt Sample accepted in error SR 01 Sample testing Sample labelled with incorrect accession label ST 05 Sample/test tubes mixed up/mislabelled ST 09 Request for pick-up Request for pick-up on wrong patient RP 01 Unit issue Unit transfusion Product issued to wrong patient UI 04 LIS warning overridden (in error or outside SOP) UI 06 Wrong type/dose of product issued to right patient UI 19 Administered product to wrong patient UT 01 Administered wrong type/dose of product to patient UT 02 Miscellaneous Patient registration incomplete/incorrect MS 03

8 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT Figure 1. Transfusion chain and types of errors that may occur at each step Canadian Blood Services Héma-Québec Secondary supplier supply blood units to hospital Transfusion Service (DC errors) Hospital Transfusion Service receives blood units, stores them & manages the inventory (PC, IM, & US errors) Doctor prescribes blood transfusion to patient. Ward collects blood samples from patient, sends them to Transfusion Service with a product request (PR, SC, & SH errors) Hospital laboratory may perform additional tests (microbiology, chemistry, hematology, etc.) (SR & ST errors) Hospital Transfusion Service receives & tests blood samples to determine what blood type is required (SR & ST errors) Transfusion Service selects, prepares unit(s) of blood based on tests results (PS & UM errors) Ward sends request for pick-up to Transfusion Service (RP errors) Transfusion Service issues unit(s) of blood to requesting wards (UI errors) Porter delivers issued unit(s) of blood to the care unit, where the patient is transfused (UT errors)

9 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT e) Case validation The P/Ts review all transfusion-related errors reported by participating hospitals from their respective jurisdictions before exporting the data to the Agency (via the TESS electronic web-based system), where a second round of review and validation for completeness and accuracy is conducted by an Agency epidemiologist and a clinical advisor. f) Statistical analysis For analytical purposes, data received from the P/Ts are extracted from the TESS electronic warehouse and consolidated into a single file in Microsoft Excel, then subjected to a pre-analytical review and validation. The file is once again transferred to another statistical software package (SAS or Stata) for final analysis, which is mainly focused on the: types of errors, occurrence and detection locations and, errors that caused harm to patient. Rates of occurrence are calculated using corresponding denominator data (as defined in Table 1) and results given per 100,000 units of products received, requested, prepared and issued, or per 100,000 samples received depending on the error type. The number of samples received and tests performed, as well as the number of units of product received, requested, prepared and issued per one error are also calculated. N.B. For the calculation of the rate of unit transfusion errors, the denominator used was the total of units of products issued because of the non-availability of the total units of product transfused.

10 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT Results a) Geographical coverage of the TESS Transfusion Services of the 15 TESS hospitals issued a total of 424,714 units of blood and blood components to their corresponding clinical services (Table 3) in 2012 and 2013. There was a significant decrease in the number of units of products received (12.4%), requested (12.5%), prepared and issued from 2012 to 2013. Table 3. Total number of blood products received/requested/prepared/issued before transfusion, TESS 2012-2013. Denominator data 2012 2013 Total Total number of samples received 144,414 136,435 280,849 Total number of tests performed 297,976 270,122 568,098 Products received a. Blood components 114,636 98,096 212,732 b. Fractionated products 100,948 90,784 191,732 c. Total number of units recieived 215,584 188,880 404,464 Products requested a. Blood components 125,499 107,582 233,081 b. Fractionated products 102,543 91,826 194,369 c. Total number of units requested 228,042 199,408 427,450 Produit Prepared a. Blood components 133,729 117,455 251,184 b. Fractionated products 103,893 93,254 197,147 c. Total number of units prepared 237,622 210,709 448,331 Products issued a. Blood components 122,934 107,548 230,482 b. Fractionated products 102,493 91,739 194,232 c. Total number of units issued 225,427 199,287 424,714

11 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT Table 4: Number of samples and blood products recived/requested/prepared/issued to hospitals by transfusion capacity, TESS 2012 2013 Denominator data Total number of samples received Total number of tests performed Total units of products received Total units of products requested Total units of products prepared Total units of products issued Hospitals of small transfusion capacity (<2,000 RBC units /year) Hospitals of medium transfusion capacity (2000-10,000 RBC units /year) Hospitals of large transfusion capacity (>10,000 RBC units/year) Total 2012 2013 2012 2013 2012 2013 2012 2013 7,513 6,607 35,673 35,960 101,228 93,868 144,414 136,435 7,722 5,593 74,102 68,071 216,152 196,458 297,976 270,122 5,623 5,002 69,669 56,512 140,292 127,366 215,584 188,880 4,790 3,880 70,945 57,195 152,307 138,333 228,042 199,408 3,291 3,162 75,168 61,719 159,163 145,828 237,622 210,709 3,782 3,186 70,795 57,319 150,850 138,782 225,427 199,287 b) Reported transfusion-related errors Overall, the TESS received reports on 17,344 transfusion-related errors that met the surveillance criteria in 2012 and 2013 from the 15 Canadian hospitals participating in the TESS and, over 80% (n=13,917) of these errors were reported from hospitals of large transfusion capacities (Tables 5 & 6). Table 5: Summary report of transfusion-related errors from hospitals of various transfusion capacities, TESS 2012-2013 Type of error n* 2012 2013 Total Hospitals of small transfusion capacity (<2,000 RBC units /year) 6 192 (2.2%) 189 (2.2%) 381 (2.2%) Hospitals of medium transfusion capacity (2000-10,000 RBC units/year) 5 1,653 (19.0%) 1,393 (16.1%) 3,046 (17.6%) Hospitals of large transfusion capacity (>10,000 RBC units /year) 4 6,853 (78.8%) 7,064 (81.7%) 13,917 (80.2%) Total 15 8,698 (100%) 8,646 (100%) 17,344 (100%) * n = number of hospitals participating in the TESS Clinical services in which highest proportions of errors occurred included medical/surgical wards 22.1% (n=3,842), emergency rooms 20.9% (n=3,617), intensive care units 11.4% (n=1,970) and outpatient clinics 11.0% (n=1,912). Transfusion Services accounted for 18.3% (n=3,172) of all the errors (Table 9). The most

12 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT common were errors related to sample collection 36.2% (n=6,278), sample handling 14.4% (n=2,489), unit transfusion 12.7% (n=2,202) and product request 7.5% (n=1,298) regardless of the transfusion capacity of reporting hospitals (Tables 6, 7 & 8)). These errors collectively account for almost 71% of all reported transfusion-related errors (Table 7). Errors that occurred the least included errors related to inventory management (IM), storage (US), product selection (PS) and which occurred respectively at a rate of 1 error per 2,889; 3,111 and 7,231 units of product received or prepared (Table s 7 & 8).

13 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT Table 6. Types of transfusion-related errors reported by hospitals participating in the TESS 2012 2013 Type of error (code) Hospitals of small transfusion capacity (<2,000 RBC units /year) Hospitals of medium transfusion capacity (2000-10,000 RBC units /year) Hospitals of large transfusion capacity (>10,000 RBC units/year) 2012 2013 2012 2013 2012 2013 2012 2013 Distributor code (DC) 16 (0.2%) 6 (0.07%) 153 (1.8%) 135 (1.6%) 264 (3.0%) 177 (2.0%) 433 (5.0%) 318 (3.7%) Product check-in (PC) 4 (0.0%) 8 (0.09%) 52 (0.6%) 35 (0.4%) 190 (2.2%) 114 (1.3%) 246 (2.8%) 157 (1.8%) Unit storage (US) 5 (0.1%) 11 (0.1%) 18 (0.2%) 12 (0.1%) 37 (0.4%) 47 (0.5%) 60 (0.7%) 70 (0.8%) Inventory management (IM) 1 (0.0%) 5 (0.06%) 19 (0.2%) 14 (0.2%) 57 (0.7%) 44 (0.5%) 77 (0.9%) 63 (0.7%) Product request (PR) 12 (0.1%) 8 (0.09%) 188 (2.2%) 126 (1.5%) 547 (6.3%) 418 (4.8%) 747 (8.6%) 552 (6.4%) Request for pick-up (RP) 3 (0.0%) 3 (0.03%) 103 (1.2%) 119 (1.4%) 258 (3.0%) 364 (4.2%) 364 (4.2%) 486 (5.6%) Product selection (PS) 1 (0.0%) 0 (0.0%) 14 (0.2%) 10 (0.1%) 23 (0.3%) 14 (0.2%) 38 (0.4%) 24 (0.3%) Unit manipulation (UM) 2 (0.0%) 0 (0.0%) 41 (0.5%) 45 (0.5%) 96 (1.1%) 72 (0.8%) 139 (1.6%) 117 (1.4%) Unit issue (UI) 2 (0.0%) 5 (0.06%) 51 (0.6%) 47 (0.5%) 71 (0.8%) 171 (2.0%) 124 (1.4%) 223 (2.6%) Unit transfusion (UT) 17 (0.2%) 10 (0.1%) 343 (3.9%) 324 (3.7%) 805 (9.3%) 703 (8.1%) 1,165 (13.4%) 1,037 (12.0%) Sample collection (SC) 24 (0.3%) 35 (0.4%) 332 (3.8%) 231 (2.7%) 2,738 (31.5%) 2,918 (33.7%) 3,094 (35.6%) 3,184 (36.8%) Sample handling (SH) 42 (0.5%) 47 (0.5%) 105 (1.2%) 105 (1.2%) 969 (11.1%) 1,221 (14.1%) 1,116 (12.8%) 1,373 (15.9%) Sample receipt (SR) 37 (0.4%) 40 (0.5%) 37 (0.4%) 28 (0.3%) 344 (4.0%) 337 (3.9%) 418 (4.8%) 405 (4.7%) Sample testing (ST) 16 (0.2%) 7 (0.08%) 112 (1.3%) 88 (1.0%) 307 (3.5%) 283 (3.3%) 435 (5.0%) 378 (4.4%) Miscellaneous (MS) 10 (0.1%) 4 (0.05%) 85 (1.0%) 74 (0.9%) 147 (1.7%) 181 (2.1%) 242 (2.8%) 259 (3%) Total 192 (2.2%) 189 (2.2%) 1653 (19%) 1,393 (16.1%) 6,853 (78.8%) 7,064 (81.7%) 8,698 (100%) 8,646 (100%) Overall

14 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT Table 7. Annual rates of different types of transfusion-related errors reported through the TESS between 2012 & 2013 Type of error (code) Freq. % 2012 2013 Overall Rate 3 per 100,000 Risk of one error 4 Freq. % Rate per 100,000 Risk of one error Freq. % Rate per 100,000 Distribution code (DC) 433 2.5% 201 1 : 498 318 1.8% 168 1 : 594 751 4.3% 186 1 : 539 Product check-in (PC) 246 1.4% 114 1 : 876 157 0.9% 83 1 : 1,203 403 2.3% 100 1 : 1,004 Unit storage (US) 60 0.3% 28 1 : 3,593 70 0.4% 37 1 : 2,698 130 0.7% 32 1 : 3,111 Inventory management (IM) 77 0.4% 36 1 : 2,800 63 0.4% 33 1 : 2,998 140 0.8% 35 1 : 2,889 Product request (PR) 747 4.3% 328 1 : 305 552 3.2% 277 1 : 361 1,299 7.5% 304 1 : 329 Product selection (PS) 38 0.2% 16 1 : 6,253 24 0.1% 11 1 : 8,780 62 0.4% 14 1 : 7,231 Unit manipulation (UM) 139 0.8% 58 1 : 1,710 117 0.7% 56 1 : 1,801 256 1.5% 57 1 : 1,751 Request for pick-up (RP) 364 2.1% 160 1 : 626 486 2.8% 244 1 : 410 850 4.9% 199 1 : 503 Unit issue (UI) 124 0.7% 55 1 : 1,818 223 1.3% 112 1 : 894 347 2.0% 82 1 : 1,224 Unit transfusion (UT) 1,165 6.7% 517 1 : 193 1,037 6.0% 520 1 : 192 2,202 12.7% 518 1 : 193 Sample collection (SC) 3,094 17.8% 2,142 1 : 47 3,184 18.4% 2,334 1 : 43 6,278 36.2% 2,235 1 : 45 Sample handling (SH) 1,116 6.4% 773 1 : 129 1,373 7.9% 1,006 1 : 99 2,489 14.4% 886 1 : 113 Sample receipt (SR) 418 2.4% 289 1 : 345 405 2.3% 297 1 : 337 823 4.7% 293 1 : 341 Sample Testing (ST) 435 2.5% 146 1 : 685 378 2.2% 140 1 : 715 813 4.7% 143 1 : 699 Miscellaneous (MS) 242 1.4% - - 259 1.5% - - 501 2.9% - - Total 8,698 50.1% - - 8,646 49.9% - - 17,344 100% - - Risk of one error 3 Rates are given per 100,000 units of products received, requested, prepared and issued/ samples received/ tests performed 4 Risk of one error are given per 100 000 units of products received, requested, prepared and issued/ samples received/ tests performed

15 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT Table 8. Rates of different types of transfusion-related errors reported through the TESS by hospitals of various transfusion capacities, TESS 2012-2013 Type of error (code) Hospitals of small transfusion capacity (<2,000 RBC units /year) Frequence (%) Rate per 100,000 Risk of one error Hospitals of medium transfusion capacity (2000-10,000 RBC units /year) Frequence (%) Rate per 100,000 Risk of one error Hospitals of large transfusion capacity (>10,000 RBC units/year) Frequence (%) Rate per 100,000 Risk of one error Frequence (%) Overall Rate per 100,000 Distribution code (DC) 22 (0.1%) 207 1 : 483 288 (1.7%) 228 1 : 438 441 (2.5%) 165 1 : 607 751 (4.3%) 186 1 : 539 Risk of one error Product check-in (PC) 12 (0.1%) 113 1 : 885 87 (0.5%) 69 1 : 1,450 304 (1.8%) 114 1 : 880 403 (2.3%) 100 1 : 1,004 Unit storage (US) 16 (0.1%) 151 1 : 664 30 (0.2%) 24 1 : 4,206 84 (0.5%) 31 1 : 3,186 130 (0.7%) 32 1 : 3,111 Inventory management (IM) 6 (0.0%) 56 1 : 1,771 33 (0.2%) 26 1 : 3,824 101 (0.6%) 38 1 : 2,650 140 (0.8%) 35 1 : 2,889 Product request (PR) 20 (0.1%) 231 1 : 434 314 (1.8%) 245 1 : 408 965 (5.6%) 332 1 : 301 1,299 (7.5%) 304 1 : 329 Product selection (PS) 1 (0.0%) 15 1 : 6,453 24 (0.1%) 18 1 : 5,704 37 (0.2%) 12 1 : 8,243 62 (0.4%) 14 1 : 7,231 Unit manipulation (UM) Request for pick-up (RP) Unit issue (UI) Unit transfusion (UT) 2 (0.0%) 31 1 : 3,227 86 (0.5%) 63 1 : 1,592 168 (1.0%) 55 1 : 1,815 256 (1.5%) 57 1 : 1,751 6 (0.0%) 86 1 : 1,161 222 (1.3%) 173 1 : 577 622 (3.6%) 215 1 : 466 850 (4.9%) 200 1 : 500 7 (0.0%) 100 1 : 995 98 (0.6%) 76 1 : 1,307 242 (1.4%) 84 1 : 1,197 347 (2.0%) 82 1 : 1,224 27 (0.2%) 387 1 : 258 667 (3.8%) 521 1 : 192 1,508 (8.7%) 521 1 : 192 2,202 (12.7%) 518 1 : 193 Sample collection (SC) 59 (0.3%) 418 1 : 239 563 (3.2%) 786 1 : 127 5,656 (32.6%) 2,899 1 : 34 6,278 (36.2%) 2,235 1 : 45 Sample handling (SH) 89 (0.5%) 630 1 : 159 210 (1.2%) 293 1 : 341 2,190 (12.6%) 1,123 1 : 89 2,489 (14.1%) 886 1 : 113 Sample receipt (SR) 77 (0.4%) 545 1 : 183 65 (0.4%) 91 1 : 1,102 681 (3.9%) 349 1 : 286 823 (4.7%) 293 1 : 341 Sample Testing (ST) 23 (0.1%) 173 1 : 579 200 (1.2%) 141 1 : 711 590 (3.4%) 143 1 : 699 813 (4.7%) 143 1 : 699 Miscellaneous (MS) 14 (0.1%) - - 159 (0.9%) - - 328 (1.9%) - - 501 (2.9%) - - Total 381 (2.2%) - - 3,046 (17.6%) - - 13,917 (80.2%) - - 17,344 (100%) - -

16 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT Table 9. Type of transfusion-related error by location of occurrence, TESS 2012-2013. Type of error (code) Blood Supplier Emergency room Intensive care unit Laboratory service Medical/ Obstetrics unit Surgical ward Operating room Outpatient clinics Supplier/ Service provider Transfusion Service Distribution code (DC) 751 (99.7 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 751 (4.3 %) Product check-in (PC) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 403 (12.7 %) 403 (2.3 %) Unit storage (US) 0 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 130 (4.1 %) 130 (0.7 %) Inventory management (IM) 0 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 140 (4.4 %) 140 (0.8 %) Product request (PR)* 0 205 (5.7 %) 230 (11.7 %) 0 (0.0 %) 431 (11.2 %) 134 (16.5 %) 89 (8.2 %) 207 (10.8 %) 2 (2.2 %) 0 (0.0 %) 1,298 (7.5%) Product selection (PS) 0 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 62 (2,0 %) 62 (0.4 %) Unit manipulation (UM) 0 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 256 (8.1 %) 256 (1.5 %) Request for pick-up (RP) 0 125 (3.5 %) 279 (14.2 %) 0 (0.0 %) 286 (7.4) 45 (5.6 %) 42 (3.9 %) 55 (2.9 %) 18 (19.4 %) 0 (0.0 %) 850 (4.9 %) Unit issue (UI) 0 0 (0.0 %) 0 (0.0 %) 4 (4.6 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 347 (10.9 %) 347 (2.0 %) Unit transfusion (UT) 0 283 (7.8 %) 600 (30.5 %) 0 (0.0 %) 536 (14.0%) 25 (3.1 %) 563 (51.7 %) 191 (10.0 %) 4 (4.3 %) 0,0 % 2,202 (12.7 %) Sample collection (SC) 0 2406 (66.5 % 549 (27.9 %) 0 (0.0 %) 1 919 (50.0 %) 379 (46.8 %) 245 (22.5 %) 777 (40.6 %) 3 (3.2 %) 0,0 % 6,278 (36.2 %) Sample handling (SH) 0 570 (15.8 %) 304 (15.4 %) 0 (0.0 %) 639 (16.6 %) 212 (26,2 %) 126 (11.6 %) 628 (32.8 %) 10 (10.,8 %) 0,0 % 2,489 (14.4 %) Sample receipt (SR) 0 0 (0.0 %) 0 (0.0 %) 24 (27.6 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 799 (25.2 %) 823 (4.7 %) Sample Testing (ST) 0 0 (0.0 %) 0 (0.0 %) 5 (5.7 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 808 (25.5 %) 813 (4.7 %) Miscellaneous (MS) 2 (0.3 %) 0.8 % 8 (0.4 %) 58 (66.7 %) 30 (0.8 %) 15 (1.9 %) 23 (2.1 %) 54 (2.8 %) 56 (60.2 %) 227 (7.2 %) 501 (2.9 %) Total Total 753 (100%) 3,617 (100 %) 1,970 (100 %) 87 (100 %) 3,841 (100%) 810 (100 %) 1,088 ( 1,912 ( 93 ( 3,172 17,343 (100%) 100 %) 100 %) 100 %) (100 %) * Information about the occurrence location of a PR related error discovered in the medical/surgical ward missing. Table 10 highlights the effectiveness of error detection processes in place within each clinical and Transfusion Service. Transfusion Services demonstrated highest efficiency as they were able to detect the vast majority of errors that originated from within (94.4%) and from other services (92.3%).

17 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT Table 10. Transfusion-related errors by locations of discovery and occurrence, TESS 2012-2013 Occurrence Discovery Blood supplier Blood supplier Emergency Intensive care unit Lab. service Medical/ Surgical ward Where error occurred Obstetrics Operating room Outpatient clincs Supplier/ Service provider Transfusion Service 4 (0.5%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 10 (0.3%) 14 (0.1%) Emergency 4 (0.5%) 108 (3.0%) 1 (0.1%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (0.1%) 1 (1.1%) 10 (0.3%) 125 (0.7%) Total Where error discovered Intensive care unit Laboratory service 7 (0.9%) 1 (0.0%) 300 (15.2%) 0 (0.0%) 4 (0.1%) 1 (0.1%) 5 (0.5%) 2 (0.1%) 3 (3.2%) 43 (1.4%) 366 (2.1%) 2 (0.3%) 4 (0.1%) 3 (0.2%) 4 (4.6%) 4 (0.1%) 0 (0.0%) 0 (0.0%) 4 (0.2%) 0 (0.0%) 0 (0.0%) 21 (0.1%) Medical/Surgical ward* 12 (1.6%) 7 (0.2%) 2 (0.1%) 0 (0.0%) 251 (6.5%) 0 (0.0%) 0 (0.0%) 1 (0.1%) 2 (2.2%) 36 (1.1%) 311 (1.8%) Obstetrics 0 (0.0%) 0 (0.0%) 1 (0.1%) 0 (0.0%) 0 (0.0%) 12 (1.5%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 3 (0.1%) 16 (0.1%) Operating room 4 (0.5%) 1 (0.0%) 0 (0.0%) 0 (0.0%) 5 (0.1%) 0 (0.0%) 169 (15.1%) 6 (0.3%) 2 (2.2%) 17 0.5%) 204 (1.2%) Outpatient clinics 3 (0.4%) 5 (0.1%) 0 (0.0%) 1 (1.1%) 1 (0.0%) 0 (0.0%) 0 (0.0%) 125 (6.5%) 1 (1.1%) 57 (1.8%) 193 (1.1%) Supplier/Service provider Transfusion Service 3 (0.4%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 4 (0.1%) 0 (0.0%) 0 (0.0%) 1 (0.1%) 0 (0.0%) 1 (0.0%) 9 (0.1%) 714 (94.8%) 3,491 (96.5%) 1,663 (84.4%) 82 (94.3%) 3,572 (93.0%) 797 (98.4%) 914 (84.0%) 1,772 (92.7%) 84 (90.3%) 2,995 (94.4%) 16,084 (92.7%) Total 753 (100%) 3,617 (100%) 1,970 (100%) 87 (100%) 3,841 (100%) 810 (100%) 1,088 (100%) 1,912 (100%) 93 (100% ) 3,172 (100%) 17,343 (100%) * Information about the occurrence location of a PR related error discovered in the medical/surgical ward missing.

18 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT c) Potential severity of reported transfusion-related errors Transfusion-related errors most commonly reported in 2012 and 2013 were of low (n=12,845; 74.1%) potential severity (Tables 11 & 12). Those of medium and high potential severity represented 8.9% (n=1,536) and 17.1% (n=2,963), respectively (Table 12). Table 11. Potential severity of reported transfusion-related errors, TESS 2012-2013 Low potential Medium potential High potential severity severity severity Total Type of error (code) Freq. % Freq. % Freq. % Freq. % Distribution code (DC) 641 3.7% 38 0.2% 72 0.4% 751 4.3% Product check-in (PC) 376 2.2% 21 0.1% 6 0.0% 403 2.3% Unit storage (US) 116 0.7% 12 0.1% 2 0.0% 130 0.8% Inventory management (IM) 124 0.7% 14 0.1% 2 0.0% 140 0.8% Product request (PR) 452 2.6% 420 2.4% 427 2.5% 1,299 7.5% Product selection (PS) 17 0.1% 35 0.2% 10 0.1% 62 0.4% Unit manipulation (UM) 178 1.0% 58 0.3% 20 0.1% 256 1.5% Request for pick-up (RP) 627 3.6% 73 0.4% 150 0.9% 850 4.9% Unit issue (UI) 204 1.2% 61 0.4% 82 0.5% 347 2.0% Unit transfusion (UT) 1,923 11.1% 222 1.3% 57 0.3% 2,202 12.7% Sample collection (SC) 5,091 29.4% 70 0.4% 1,117 6.4% 6,278 36.2% Sample handling (SH) 1,625 9.4% 134 0.8% 730 4.2% 2,489 14.4% Sample receipt (SR) 630 3.6% 110 0.6% 83 0.5% 823 4.8% Sample Testing (ST) 511 2.9% 216 1.2% 86 0.5% 813 4.7% Miscellaneous (MS) 330 1.9% 52 0.3% 119 0.7% 501 2.9% Total 12,845 74.1% 1,536 8.9% 2,963 17.1% 17,344 100% Table 12. Transfusion errors of different levels of potential severity reported by different group of hospitals, TESS 2012-2013 Small transfusion Medium transfusion Large transfusion capacity hospitals capacity hospitals capacity hospitals Total Type of error (code) Freq. % Freq. % Freq. % Freq. % Low potential severity 294 77.2% 2,011 66.0% 10,540 75.7% 12,845 74.1% Medium potential severity 34 8.9% 369 12.1% 1,133 8.1% 1,536 8.9% High potential severity 53 13.9% 666 21.9% 2,244 16.1% 2,963 17.1% Total 381 100% 3,046 100% 13,917 100% 17,344 100%

19 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT d) Transfusion-related errors that did not reach the patients Approximately 93.4% (n=16,193) of the transfusion-related errors reported in 2012 and 2013 were detected before they reached the patients (Table 13). Planned detection procedures in place in hopitals participating in the TESS were credited with the detection of 97.7% (n=15,817) of these errors (Table 14a). The remaining 2.3% (n=376) were detected through unplanned procedures i.e. by chance. Table 13: Errors that did not reach the patients by occurrence & detection locations (n=16,193), TESS 2012-2013 Occurrence Supplier/ Blood Emergency Intensive care Lab. Medical/ Operating Outpatient Transfusion Obstetrics Service Total supplier Room unit Service Surgical Unit Room clinics Service Discovery provider Blood supplier 4 (0.6%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 10 (0.3%) 14 (0.1%) Emergency Room 4 (0.6%) 93 (2.7%) 1 (0.1%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (1.3%) 8 (0.3%) 107 (0.7%) Intensive care unit 6 (0.8%) 1 (0.0%) 274 (16.5%) 0 (0.0%) 3 (0.1%) 1 (0.1%) 4 (0.4%) 2 (0.1%) 2 (2.6%) 25 (0.9%) 318 (2.0%) Laboratory service 2 (0.3%) 4 (0.1%) 3 (0.2%) 3 (3.5%) 4 (0.1%) 0 (0.0%) 0 (0.0%) 4 (0.2%) 0 (0.0%) 0 (0.0%) 20 (0.1%) Medical/Surgical Unit 10 (1.4%) 5 (0.1%) 1 (0.1%) 0 (0.0%) 181 (5.1%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (1.3%) 24 (0.8%) 222 (1.4%) Obstetrics 0 (0.0%) 0 (0.0%) 1 (0.1%) 0 (0.0%) 0 (0.0%) 9 (1.2%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 3 (0.1%) 13 (0.1%) Operating room 4 (0.6%) 1 (0.0%) 0 (0.0%) 0 (0.0%) 2 (0.1%) 0 (0.0%) 167 (15.8%) 5 (0.3%) 2 (2.6%) 10 (0.3%) 191 (1.2%) Outpatient clinics 2 (0.3%) 2 (0.1%) 0 (0.0%) 0 (0.0%) 1 (0.0%) 0 (0.0%) 0 (0.0%) 110 (5.9%) 0 (0.0%) 44 (1.5%) 159 (1.0%) Supplier/Service provider 3 (0.4%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 4 (0.1%) 0 (0.0%) 0 (0.0%) 1 (0.1%) 0 (0.0%) 1 (0.0%) 9 (0.1%) Transfusion Service 681 (95.1%) 3,384 (97%) 1,377 83.1%) 82 (96.6%) 3,357 (94.5%) 762 (98.7%) 884 (83.8%) 1,728 (93.4%) 71 (92.2%) 2,814 (95.7%) 15,140 (93.5%) Total 716 (100%) 3,490 (100%) 1,657 (100%) 85 (100%) 3,552 (100%) 772 (100%) 1,055 (100%) 1,850 (100%) 77 (100%) 2,939 (100%) 16,193 (100%) Transfusion Services demonstrated highest efficiency for detecting not only from within the blood bank, but also from clinical areas. Transfusion Services detected 93.5% (n=15,140) of the transfusion-related errors that did not reach the patients; this included 95.7% (n=2,939) of their of their own errors (Table 13).

20 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT The overwhelming majority (97.7%; n=15,817) of transfusion-related errors that did not reach the patients was detected through planned detection procedures(table 14a). of those that were discovered though uplanned procedures (n=376), the most commonly reported (Table 14b) were related to product request (10.9%; n=41), sample testing (16.8%; n=63) and unit transfusion (19.9%; n=75). Also, Transfusion Services accounted for 43.4% (n=163) of all these errors, followed by medical/surgical wards (n=67) and emergency rooms (n=45) which posted 17.8% and 12.0%, respectively (Table 14b). Table 14a. Location of occurrence of transfusion-related errors that did not reach the patients & were detected through planned procedures (n=15,817), TESS 2012-2013 Type of error (code) Blood Supplier Emergency Intensive care Laboratory Medical/ Obstetrics unit Operating Outpatient Supplier/ Transfusion Total room unit service Surgical ward room clinics Service Service provider Distribution code (DC) 701 (4.4 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 701 (4.4 %) Product check-in (PC) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 387 (2.4 %) 387 (2.4 %) Unit storage (US) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 121 (0.8 %) 121 (0.8 %) Inventory management (IM) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 124 (0.8 %) 124 (0.8 %) Product request (PR) 0 (0.0 %) 137 (0.9 %) 148 (0.9 %) 0 (0.0 %) 320 (2.0 %) 131 (0.8 %) 79 (0.5 %) 188 (1.2 %) 2 (0.0 %) 0 (0.0 %) 1,005 (6.4%) Request for pick-up (RP) 0 (0.0 %) 83 (0.5 %) 94 (0.6 %) 0 (0.0 %) 171 (1.1 %) 16 (0.1 %) 35 (0.2 %) 40 (0.3 %) 6 (0.0 %) 0 (0.0 %) 445 (2.8 %) Product selection (PS) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 29 (0.2 %) 29 (0.2 %) Unit manipulation (UM) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 223 (1.4 %) 223 (1.4 %) Unit issue (UI) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 259 (1.6 %) 259 (1.6 %) Unit transfusion (UT) 0 (0.0 %) 254 (1.6 %) 571 (3.6 %) 0 (0.0 %) 455 (2.9 %) 23 (0.1 %) 535 (3.4 %) 172 (1.1 %) 4 (0.0 %) 0 (0.0 %) 2,014 (12.7 %) Sample collection (SC) 0 (0.0 %) 2,392 (15.1 % 542 (3.4 %) 0 (0.0 %) 1,909 (12.1 %) 372 (2.4 %) 241 (1.5 %) 768 (4.9 %) 3 (0.0 %) 0 (0.0 %) 6,227 (39.4 %) Sample handling (SH) 0 (0.0 %) 560 (3.5 %) 277 (1.8 %) 0 (0.0 %) 612 (3.9 %) 209 (1.3 %) 122 (0.8 %) 67 (3.8 %) 6 (0.0 %) 0 (0.0 %) 2,393 (15.1 %) Sample receipt (SR) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 20 (0.1 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 734 (4.6 %) 754 (4.8 %) Sample Testing (ST) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 4 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 691 (4.4 %) 695 (4.4 %) Miscellaneous (MS) 2 (0.0 %) 19 (0.1 %) 7 (0.0 %) 57 (0.4 %) 18 (0.1 %) 12 (0.1 %) 19 (0.1 %) 46 (0.3 %) 52 (0.3 %) 208 (1.3 %) 440 (2.8 %) Total 703 (4.4%) 3,445 (21.8 %) 1,639 (10.4%) 81 (0.5 %) 3,485 (22.0%) 763 (4.8 %) 1,031 ( 1,821 (11.5 73 ( 2,776 15,817 (100%) 6.5 6.5%) 11.511 %) 11.5 0.5%) (17.6 %)

21 TRANSFUSION ERROR SURVEILLANCE SYSTEM: 2012-2013 REPORT Table 14b. Location of occurrence of transfusion-related errors that did not reach the patients & were detected through unplanned procedures (n=376), TESS 2012-2013 Intensive care Laboratory Medical/ Obstetrics unit Operating Outpatient Supplier/ Transfusion Total Emergency Type of error (code) Blood Supplier unit service Surgical ward room clinics Service Service room provider Distribution code (DC) 13 (3.5 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 13 (3.5 %) Product check-in (PC) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 11 (2.9 %) 11 (2.9 %) Unit storage (US) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 7 (0.8 %) 7 (1.9 %) Inventory management (IM) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 6 (1.6 %) 6 (1.6 %) Product request (PR) 0 (0.0 %) 12 (3.2 %) 3 (0.8 %) 0 (0.0 %) 17 (4.5 %) 0 (0,0 %) 3 (0.8 %) 6 (1.6 %) 0 (0.0 %) 0 (0.0 %) 41 (10.9 %) Request for pick-up (RP) 0 (0.0 %) 0 (0.0 %) 2 (0.5 %) 0 (0.0 %) 9 (2.4 %) 0 (0,0 %) 2 (0.5 %) 2 (0.5 %) 2 (0.5 %) 0 (0.0 %) 17 (4.5 %) Product selection (PS) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 6 (1.6 %) 6 (1.6 %) Unit manipulation (UM) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 9 (2.4 %) 9 (2.4 %) Unit issue (UI) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 28 (7.4 %) 28 (7.4 %) Unit transfusion (UT) 0 (0.0 %) 15 (4.0 %) 9 (2.4 %) 0 (0.0 %) 30 (8.0 %) 1 (0.3 %) 14 (3.7 %) 6 (1.6 %) 0 (0.0 %) 0 (0.0 %) 75 (19.9 %) Sample collection (SC) 0 (0.0 %) 10 (2.7%) 3 (0.8 %) 0 (0.0 %) 6 (1.6 %) 4 (1.1 %) 2 (0.5 %) 4 (1.1 %) 0 (0.0 %) 0 (0.0 %) 29 (7.7 %) Sample handling (SH) 0 (0.0 %) 3 (0.8 % 1 (0.3 %) 0 (0.0 %) 1 (0.3 %) 1 (0.3 %) 0 (0.0 %) 8 (2.1 %) 1 (0.3 %) 0 (0.0 %) 15 (4.0 %) Sample receipt (SR) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 3 (0.8 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 21 (5.6 %) 24 (6.4 %) Sample Testing (ST) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 63 (16.8 %) 63 (16.8 %) Miscellaneous (MS) 0 (0.0 %) 5 (1.3 %) 0 (0.0 %) 1 (0.3 %) 4 (1.1 %) 3 (0.8 %) 3 (0.8 %) 3 (0.8 %) 1 (0.3 %) 12 (3.2 %) 32 (8.5 %) 13 (3.5%) 45 (12.0 %) 18 (4.8%) 4 (1.1 %) 67 (17.8%) 9 (2.4 %) 24 ( 29 (7.7 4 (1.1 163 376 (100%) Total 6.5 6.4%) 11.511 %) 11.5 %) (17.6 %) Transfusion Services also showed high efficiency in detecting errors through unplanned procedures as they accounted for the detection of 79.8% (n=300) of all the errors that did not reach the patients including 95.1% (n=155) of theirs (Table 15).