Table 28 'Wrong Blood Type'

PSI 27: Wrong blood type
Origin: Review of an OECD PSI (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. Half of the reported deaths due to
major complications of transfusion in United Kingdom were shown a
consequence of transfusing the wrong blood to a patient. Reports from
a period of two years from October 1996 of death or major
complications of transfusions revealed that he most common (52%)
adverse event was giving the wrong blood type to the patient. Thus
wrong blood type is a suitable measure of patient safety.
Aim of the PSI This PSI is intended to flag cases of patients given the wrong blood
type.
Level of Determination of
Patient Safety
Safety can be assessed at the individual and the aggregated patient
level. Though du to the rarity of the wrong blood type and the severity
of the event, safety is recommended assessed at the individual patient
level.
Source(s) This indicator was originally proposed by the Australian Council for
Safety and Quality.
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 cover patient safety.
The results suggest that this PSI may be useful as a measure of patient
safety (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 Not specified.
Numerator Description Number of haemolytic blood transfusion reaction resulting from ABO
incompatibility.
Denominator Description All transfusions.
Data Source Not specified.
Identifying the
institutional context
The impact of this PSI theme is important for both financial and quality
improvement policies.
SImPatIE WP4 – Catalogue of Patients Safety Indicators
74
Care Setting The PSI applies for 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.
Standard of Comparison No specific standards given.
Scoring No scoring advice given.