Today we will be discussing a newly formed United States hemovigilance system that tracks adverse reactions related to transfusions. While transfusions are the most common medical procedure performed in the United States, adverse reactions ranging from mild allergic reactions to severe life-threatening events can occur.
Dr. Roger Dodd who wrote an editorial on the subject adds:
“The hemovigilance system is important because really we don’t accurately know how many adverse events there are and, therefore, we don’t know where best to focus our efforts to support patient heath. For example the British system recognized the problems caused by TRALI and were able to figure out that many of the cases were attributable to donations from female donors.”
The CDC in collaboration with transfusion experts from the AABB formed the Hemoviligance Module. The Hemoviligance Module is an internet-based tracking system which is part of the National Healthcare Safety Network used by more than 12,000 U.S. health care facilities.
From 2010 to 2012, the first three years the system was in place, 77 health care facilities entered at least one month of data and reported transfusing over 2.1 million blood components with 5136 transfusion reactions. Almost 83% of these adverse events were either allergic or febrile nonhemolytic reactions. Just over 7% of reactions were severe or life-threatening, and 0.1% were fatal. Platelet were associated with the highest transfusion reaction rate.
Dr. Dodd comments:
“Hemovigilance is now an expected standard for blood systems worldwide. The data is similar to those from comparable systems in other developed countries even though the program is in its infancy.”
Only a small fraction of U.S. health care facilities contributed to this study, and less than 5% of all U.S. transfusions were reported. Furthermore, there is no review mechanism in place to evaluate the accuracy of reported data.
Dr. Dodd adds:
“We realize that it’s early in the program and we anticipate that there will be a great deal of improvement over time. We believe that the AABB Center for Patient Safely can contribute by working with member institutions that are able to confidentially share their clinical data for comparison with information reported for CDC.”
Developing a strong hemovigilance system will allow specific adverse reactions to be identified and then, hopefully, reduced to improve the safety of transfusions.
We’ll be back with another edition of Transfusion News on April 30. Thanks for joining us.
1. Dodd RY, Katz LM. Qui custodiet ipsos custodes? Transfusion 2015;55:693-695.
2. Harvey AR, Basavaraju SV, Chung KW, Kuehnert MJ. Transfusion-related adverse reactions reported to the National Healthcare Safety Network Hemovigilance Module, United States, 2010 to 2012. Transfusion 2015;55:709-718.