The Norwegian Knowledge Centre for the Health Services runs the Norwegian Haemovigilance System, Troll, on behalf of the Norwegian Directorate of Health. One of our tasks is to publish an annual report. The purpose of this report is to form the knowledge basis for the continuous improvement of the transfusion services.
This report describes adverse outcomes of blood transfusion and incorrect blood component transfused (IBCT) in Norway in 2012, based on reports to the Norwegian Haemovigilance System.
Health personnel report adverse outcomes of blood transfusion and IBCT electronically on www.hemovigilans.no. The system is mandatory for serious adverse reactions and events according to the EU blood directive. Mild adverse reactions are reported on a voluntary basis. The system is confidential.
Definitions are based on standards proposed by the International Haemovigilance Network and ISBT-WP on haemovigilance. The Haemovigilance task group analyses incoming reports. The data is analysed using the statistical program SPSS. Background and method are further described in the 2010 report.
Approximately 265 000 units of red blood cell concentrates, platelet concentrates and plasma (Octaplas®) were transfused in Norway in 2012. The Haemovigilance System received 215 reports on adverse outcomes of transfusion and IBCT, 81 per 100 000 transfusions. Thirty-three (12.4 per 100 000) were reported as severe, life threatening or fatal. Febrile non-haemolytic reactions and mild allergic reactions were most frequently reported. Eleven anaphylactic reactions, 16 cases of transfusion associated circulatory overload (TACO) and five cases of transfusion-related acute lung injury (TRALI) were reported. One of the TRALI cases was fatal.
No transfusion-transmitted infection was reported. Twenty patients were transfused with incorrect blood component. Nine patients received blood intended for another patient. In all events, the bedside identity control was not performed according to national guidelines. Two of the patients got ABO hemolytic transfusion reaction. Both recovered completely. The haemovigilance system received 25 % more reports in 2012 than in 2011. The incidence of complications reported as serious is also increasing. It is hard to tell whether this is due to random variations, a real increase in the number of events or an increase in the proportion of incidents that are reported.
The haemovigilance system seems to be well accepted, as all hospitals are reporting. The system provides good information about the incidence of the different transfusion complications. However, it is not suitable for comparing hospitals. Some adverse events are preventable. It is important that health personnel is familiar with these events and know how to prevent them. Adverse reactions due to IBCT are preventable. TRALI and TACO are partly preventable reactions.
It is safe to receive blood in Norway. There is a small risk of serious complications. The Haemovigilance Task Group has provided recommendations to further reduce this risk.