Risk management in hospital “Blood Transfusion Chain”

The understanding of the risks within the “Blood Transfusion Chain” is the best way to improve the Blood safety and Patient safety overall. The minimal number of transfusion reactions and adverse events does not indicate total safety. The aim of this research was to reduce or maintain the risk at an acceptable level by analyzing processes, critical points and data. A retrospective case series study was conducted by analyzing Haemovigilance data, patient safety reports and transfusion reactions, performed in Children’s Clinical University Hospital in Latvia from 01.01.2016. to 01.10.2020. Insufficient number of Haemovigilance data hindered adequate quantitative analysis. Case studies for every adverse event and reaction were more useful than statistical analysis. Among 8552 blood transfusions, 29 patient safety events, 47 adverse events and 9 adverse reactions were reported. Two main risks were identified: 1) the risk to blood component’s quality and availability: integrity; bacterial contamination; blood handling processes; pre-transfusion actions; impact of the COVID-19; 2) the risk for the patient safety: identification; correct pre-transfusion, transfusion and post-transfusion processes, as well as the correlation between both risks.  Standardization and validation for risk reduction and maintenance, risk management at all stages, reporting data and analyzing were improved to control the trends. There is a positive correlation between the Hospital’s culture in “Blood Transfusion Chain” and Patient safety. Six step risk management process (planning, risk identification, qualitative and quantitative analysis, determination of adequate risk response and risk control) was the effective tool to search decisions for improvement of Blood Supply in COVID-19 pandemic conditions, to optimize Blood Stock management and mitigate the Patient safety risks.