Table 27 'Transfusion Reaction'

PSI 26: Transfusion Reaction
Origin: Review of OECD/AHRQ/CIHI PSI (3;33)
Dimension Description
Description of Specific
Aspects of Patient Safety
The chance of a patient suffering a fatal transfusion reaction due to
ABO-incompatibility is roughly equivalent to the risk of acquiring HIV
infection from a blood transfusion. Thus transfusion reaction is an
important measure of patient safety.
Aim of the PSI This indicator is intended to flag cases of major reactions due to
transfusions.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This indicator was originally proposed by Iezzoni et al. as part of the
Complications Screening Program (CSP “sentinel events”). It was also
included as one component of a broader PSI for “adverse events and
iatrogenic complications” in AHRQs original HCUP Quality
Indicators.
It was proposed by Miller et al. in the original “AHRQ PSI
Algorithms and Groupings (33).
Extent of Clinically
Testing
The OECD Health Care Quality Indicators (HCQI) Project was
initiated to implement quality measures for international
benchmarking of medical care at the health system level. Five priority
areas including patient safety were selected. International expert
panels were formed to identify clinically important, scientifically
sound, and feasible measures based on a structured consensus process.
The consensus process was successfully completed in all five priority
areas leading to a recommendation of 86 indicators of which 21
covered patient safety (33).
The AHRQ project team developing the PSI conducted empirical
analyses on this PSI. Given the low rates or occurrences for
Transfusion Reaction, the team did not measure reliability or minimum
bias. The indicator could not be risk-adjusted due to the small number
of numerator cases. The Literature review conducted by the ARHQ
team did not reveal evidence on validity from prior studies, it was
explained due to the rarity of this complication (3).
The AHRQ PSI software was applied to Veteran Affairs (VA)
administrative data to identify potential instances of compromised
patient safety; determine occurrence rates of PSI events in the VA;
and examine the construct validity of the PSIs. The study population
was 97% male, with a mean age of 65 years, 54% were age 65 and
older. Mean length of stay was 7.1.days. All together 11411 PSI
events were identified, 46% of PSI events occurred in surgical
hospitalisation and 54% in medical hospitalisation. The observed PSI
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rate per 1000 discharges was 0.007 the lowest of all studied for
transfusion reaction. No statistically significant differences were
found for hospitalisations with this PSI events and those without PSI
events for longer lengths of stay, higher mortality and higher costs (4).
The performance of the AHRQ PSIs was analysed to: 1) provide a
descriptive analysis of the incidence of PSI events from 2001 to 2004
in the VA; 2) examine trends in national PSI rates at the hospital
discharge level over time; and 3) assess whether hospital
characteristics (teaching status, number of beds, and degree of quality
improvement implementation) and baseline safety-related hospital
performance predict future hospital safety-related performance. Riskadjusted
rates of the PSI for iatrogenic pneumothorax and failure to
rescue demonstrated a consistent rate over time. It was concluded, that
the PSIs are useful tools for tracking and monitoring patient safety
events. Future research should investigate whether trends reflect better
or worse care or increased attention to documenting patient safety
events (5).
AHRQ is determining the feasibility and practicality in a project
concerning validation of selected AHRQ Quality Indicators (8).
The results suggest that this PSI may be useful as a measure of patient
safety (3-5;33).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: ”Medication Error”.
Data definitions Cases of transfusion reaction per 1000 discharges.
Numerator Description Discharges with ICD-9-CM codes for transfusion reaction in any
secondary diagnosis field per 100 discharges.
Denominator Description All medical and surgical discharges.
The OECD expert panel recommended changing the original AHRQdenominator
to: “all transfusions”.
Data Source Administrative data.
Identifying the
institutional context
The impact of transfusion reactions makes this PSI important for both
financial and quality improvement policies.
Care Setting The PSI applies for high quality transfusion care.
Professionals Responsible
for Health Care
Doctors.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
No risk adjustment described.
Stratification by
Vulnerable Populations
No stratification.
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Standard of Comparison No specific standards given.
Scoring AHRQ has PSI software for scoring. Users of the PSI software should
note the output will only contain observed rates of transfusion reaction
(3).