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    Hemovigilance Pasien

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    widia
    This document discusses haemovigilance and adverse reactions related to blood transfusions. It defines key terms like adverse reactions, incidents, and near misses. It describes the severity grading of adverse reactions from grade 1 to 4. It identifies hotspots for errors in clinical decisions, specimen collection, issuing blood, and laboratory testing. It emphasizes the importance of following standard operating procedures and checking patient identification at all steps to minimize risks. It recommends transfusing blood in single units and reassessing patients before additional units. Overall, the document provides guidelines for monitoring haemovigilance and reducing errors to improve safety in blood transfusions.

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    Hemovigilance Pasien

    Uploaded by

    widia
    38 views21 pages
    This document discusses haemovigilance and adverse reactions related to blood transfusions. It defines key terms like adverse reactions, incidents, and near misses. It describes the severity grading of adverse reactions from grade 1 to 4. It identifies hotspots for errors in clinical decisions, specimen collection, issuing blood, and laboratory testing. It emphasizes the importance of following standard operating procedures and checking patient identification at all steps to minimize risks. It recommends transfusing blood in single units and reassessing patients before additional units. Overall, the document provides guidelines for monitoring haemovigilance and reducing errors to improve safety in blood transfusions.

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    Komponen darah

    Original Title

    12. Hemovigilance pasien

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    This document discusses haemovigilance and adverse reactions related to blood transfusions. It defines key terms like adverse reactions, incidents, and near misses. It describes the severity grading of adverse reactions from grade 1 to 4. It identifies hotspots for errors in clinical decisions, specimen collection, issuing blood, and laboratory testing. It emphasizes the importance of following standard operating procedures and checking patient identification at all steps to minimize risks. It recommends transfusing blood in single units and reassessing patients before additional units. Overall, the document provides guidelines for monitoring haemovigilance and reducing errors to improve safety in blood transfusions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    38 views21 pages

    Hemovigilance Pasien

    Uploaded by

    widia
    This document discusses haemovigilance and adverse reactions related to blood transfusions. It defines key terms like adverse reactions, incidents, and near misses. It describes the severity grading of adverse reactions from grade 1 to 4. It identifies hotspots for errors in clinical decisions, specimen collection, issuing blood, and laboratory testing. It emphasizes the importance of following standard operating procedures and checking patient identification at all steps to minimize risks. It recommends transfusing blood in single units and reassessing patients before additional units. Overall, the document provides guidelines for monitoring haemovigilance and reducing errors to improve safety in blood transfusions.

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    © All Rights Reserved
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    of 21

    HEMOVIGILANCE

    PASIEN

    Dr Errisa Maisuritadevi Mara, M.Sc., Sp.PK


    Apa Itu Haemovigilance ?
    Untuk Pasien ....
    REAKSI TRANSFUSI
    adverse reaction
    adalah "respons atau efek yg tidak diinginkan" pada pasien
    terkait dg pemberian transfusi darah atau komponen
    darah.
    • Dapat terjadi akibat dari suatu insiden, tetapi tidak selalu

    NHSN manual: biovigilance component protocol hemovigilance module, June 2011.


    Guidelines and procedures for monitoring hemovigilance. http://www.cdc.gov/nhsn/bio.html.
    Transfusion Related Activities
    Adverse KEJADIAN YG TIDAK DIHARAPKAN yg terjadi
    event sebelum, selama atau setelah transfusi darah.
    = KTD Termasuk insiden dan adverse reactions.

    Adverse Respons atau efek yg tidak diinginkan pd pasien yg


    reaction terkait dg pemberian transfusi darah. Dapat terjadi
    = EFEK akibat dari suatu insiden, tetapi tidak selalu
    SAMPING
    INSIDEN Setiap error atau accident yg dapat mempengaruhi
    kualitas atau efikasi transfusi pd pasien.
    Dapat menimbulkan reaksi yg merugikan pada
    recipient transfusi.

    Near miss Any error OR a subset of incidents that is discovered


    before the start of the transfusion and that could
    have led to a wrongful transfusion or to a adverse
    reaction in a transfusion recipient
    SEVERITY Adverse reaction
    GRADE
    1 Non severe -- the recipient may have required medical intervention (e.g. symptomatic
    treatment) but lack of such would not result in permanent damage or impairment of a
    body function.

    2 Severe- needs medical intervention or prolongation of


    hospitalisation, or both

    3 Life threatening; required major intervention following the transfusion


    (vasopressors, intubation, transfer to intensive care) to prevent death

    4 Death as a result of adverse transfusion reaction


    HOTSPOTS FOR ERRORS
    “WRONG BLOOD”
    CLINICAL DECISION
    What can go wrong? Why it goes wrong?
     Unnecessary transfusion or  Inadequate clinical assessment
    failure to give necessary
     Lack of transfusion knowledge or
    transfusion
    failure to follow guideline
     Wrong component or dose
     Unaware of importance of
    prescribed
    information & consent
     Patient was not informed &
    consent not obtain
    SPECIMEN COLLECTION
    What can go wrong? Why it goes wrong?
     Patient was not identified  Do not follow SOP for specimen
    correctly collection
     Pre transfusion specimen taken  Staff takes shortcut
    from wrong patient
     Request form/ sample tube was
    wrongly labeled
    ISSUING/DELIVERY OF BLOOD
    What can go wrong? Why it goes wrong?
     Wrong unit selected  Patient ID details not properly
     Blood delivered to wrong checked
    location  SOP was not followed
     Wrong storage
    LABORATORY ERROR

    What can go wrong? Why it goes wrong?


     Wrong ABO/ Rh grouping  Patient sample and request not
     RBC alloantibodies not detected checked for consistency and
    completeness
     Error in crossmatch & wrong unit
    issued  Error in testing procedure or
    recording of result
     Poor staff training or failure to
    comply with SOP
    EVERY ONE MATTERS

    Transfuse One Unit

    Re-assess the patient

    Don’t increase the RISKS


    if NO BENEFIT
    The Serious Hazard of Transfusion (SHOT) scheme
    showed that approximately 70% of IBCT event errors
    take place in clinical areas, the most frequent error
    being failure of the final patient ID check at the bedside.

    (Serious Hazards of Transfusion (SHOT) 2007)


    SINGLE UNIT TRANSFUSION

    WHAT
    Transfuse one unit, then re-assess the patient for clinical
    symptoms before transfusing another
     Every unit is a new clinical decision
     Base decision on patient symptoms, not only on haemoglobin
    level
    SEROLOGY
    REAKSI TRANSFUSI
    Risks and problems in the different key processes in the context of a
    blood transfusion in a HOSPITAL
    Actions and measures
    http://haemovigilanceindo.com

    Mari Bergabung

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