输血不良反应发生与漏报情况调查及对策

Survey and countermeasure on the occurrence and underreporting of transfusion reaction

目的调查本院输血不良反应发生及漏报情况,规范输血管理工作,提高安全输血水平。方法回顾分析本院1 096名输血患者的临床资料,调查输血不良反应的发生情况与漏报率。结果 1 096名输血患者共计输血3583次,有81次发生输血不良反应,过敏反应68次占77.78%(68/81),非溶血性发热反应13次占22.22%(13/81)。各种血液制品发生输血不良反应的比率依次是单采血小板7.44%(32/430),血浆3.36%(32/953),冷沉淀3.03%(3/99),去白细胞红细胞悬液0.67%(14/2 101)。其中只有23次有输血不良反应回报单反馈至输血科,回报率只有28.40%(23/81),漏报率71.60%(58/81)。结论输血不良反应漏报率较高,仅凭不良反应回报单不能全面反映实际发生情况,应加强输血不良反应发生情况监控,提高规范用血意识,促进医疗安全。

Objective To improve the safety level of transfusion,to investigate the occurrence and underreporting of transfusion reaction in our hospital and to standardize the management of transfusion. Methods Clinical data,including 1096 cases transfused in our hospital,were reviewed and analyzed. The occurrence and underreporting of transfusion reaction was investigated. Results The 1 096 cases had 3 583 transfusions in total. There were 81 cases of transfusion reactions,68 cases of allergic reaction that accounted for 77. 78%（ 68 /81）,and 13 cases of febrile non-hemolytic transfusion reactions that accounted for 22. 22%（ 13 /81）. The transfusion reaction rates of each blood products are respectively： apheresis platelet was 7. 44%（ 32 /430）,plasma was 3. 36%（ 32 /953）,cryoprecipitate was 3. 03%（ 3 /99）,and erythrocyte was0. 67%（ 14 /2101）. Only 23 cases returned the transfusion reaction reports to blood transfusion branch at a rate of only28. 40%（ 23 /81）. The underreporting rate was 71. 60%（ 58 /81）. Conclusion The underreporting rate of transfusion reaction is high. It cannot reflect the actual situation on the sole basis of return report. In order to promote medical safety,improvement should be made to monitor the incidences of transfusion reaction and enhance the awareness on clinical blood use.