Exploring patient participation in reducing health-care-related safety risks
Exploring patient participation in reducing health-care-related safety risks
Exploring patient participation in reducing health-care-related safety risks
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Box A3 .1 . Report<strong>in</strong>g procedure<br />
Patient <strong>in</strong>volvement <strong>in</strong> blood transfusion <strong>in</strong> the Netherlands<br />
Reports of transfusion reactions are sent to TRIP on a voluntary basis and are treated confidentially. Data<br />
analysis and report<strong>in</strong>g are anonymous. Report<strong>in</strong>g to TRIP is separate from the regular communication methods<br />
between hospitals and the supply<strong>in</strong>g Sanqu<strong>in</strong> blood banks about transfusion reactions or <strong>in</strong>cidents.<br />
Who<br />
» The hospital submits a report if a reaction has been noted <strong>in</strong> the hospital.<br />
» The Sanqu<strong>in</strong> blood bank submits a report if a problem has been detected by the blood bank after delivery<br />
of a blood component to a hospital. TRIP’s po<strong>in</strong>t of contact <strong>in</strong> each of the four supply<strong>in</strong>g divisions is the<br />
manager of the cl<strong>in</strong>ical advisory service.<br />
» TRIP checks for double report<strong>in</strong>g by compar<strong>in</strong>g product numbers.<br />
Responsible persons at hospital level<br />
» Haemovigilance officer, a staff member officially responsible for report<strong>in</strong>g to TRIP, nom<strong>in</strong>ated by the<br />
Blood Transfusion Committee and preferably officially appo<strong>in</strong>ted by the hospital board.<br />
» Haemovigilance assistant, who prepares the report to TRIP (visits ward, collects and collates <strong>in</strong>formation),<br />
assists the haemovigilance officer and provides education and tra<strong>in</strong><strong>in</strong>g on blood transfusion.<br />
What<br />
Transfusion reaction (TRIP def<strong>in</strong>ition)<br />
» Any undesired medical event (symptom, sign or diagnosis) or worsen<strong>in</strong>g of a pre-exist<strong>in</strong>g medical<br />
condition dur<strong>in</strong>g and/or after a blood transfusion.<br />
» Period: from the order<strong>in</strong>g of the transfusion until an unlimited time after adm<strong>in</strong>istration of a blood<br />
component.<br />
» Imputability: rat<strong>in</strong>g the likelihood that the undesired event was due to the transfusion of the blood<br />
component.<br />
» More: categories of reactions that are to be reported to TRIP. 1<br />
How<br />
How to report<br />
Department where reaction is detected<br />
» Treat/act accord<strong>in</strong>g to hospital protocol; discuss with the consultant <strong>in</strong> charge.<br />
» Treat<strong>in</strong>g team sends report to blood transfusion laboratory.<br />
Blood transfusion laboratory<br />
» Further tests accord<strong>in</strong>g to hospital procedures.<br />
» Report to supply<strong>in</strong>g blood bank if appropriate.<br />
Report to TRIP (hospital haemovigilance officer)<br />
» Report to TRIP, generally after conclusion of <strong>in</strong>vestigation.<br />
» Send <strong>in</strong> completed reports at least every three months.<br />
» Please do not “save up” reports of grade II reactions (or higher), but <strong>in</strong>stead submit when results of<br />
<strong>in</strong>vestigations are complete.<br />
Publication of results<br />
Communication with hospitals (currently 110 addresses)<br />
» TRIP confirms receipt of reports to the submitt<strong>in</strong>g party.<br />
» Each hospital receives a prelim<strong>in</strong>ary overview of (national) reports to date every six months and (if there<br />
has been no communication) a “noth<strong>in</strong>g to report” card to confirm <strong>participation</strong>.<br />
» Personal contacts are ma<strong>in</strong>ta<strong>in</strong>ed through regional meet<strong>in</strong>gs and visits to <strong>in</strong>dividual hospitals where<br />
possible.<br />
Annual report<br />
The submitted reaction reports are reviewed by an expert panel of board members. Any discrepancies <strong>in</strong> the<br />
assignment to a particular category of reaction, grad<strong>in</strong>g or classification of imputability are resolved by discussion<br />
with the report<strong>in</strong>g party. The annual report is sent (with analyses and recommendations) to the report<strong>in</strong>g<br />
haemovigilance officers, blood transfusion committees and govern<strong>in</strong>g boards of the hospitals, to the other<br />
participat<strong>in</strong>g organizations and to the M<strong>in</strong>istry of Health, Welfare and Sports. A summary <strong>in</strong> English is made<br />
available on request.<br />
Publication <strong>in</strong> relevant scientific journals is envisaged.<br />
1 See Box A3.2 and the TRIP web site for more details (2).<br />
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