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Experience with Analyzing Patient Safety Incident Reports and Applying Corrective Action in a Blood Bank 有分析血库患者安全事故报告和采取纠正措施的经验
Pub Date : 2019-12-31 DOI: 10.17945/kjbt.2019.30.3.212
M. Kim, Hyun Ji Lee, Soo Hwa Kang, S. Lee, I. Kim, Chulhun L. Chang
Background: Blood transfusion poses high risks and has a high probability of error because of the complexity and involvement of several people in the process. The purpose of this study was to share our experience in classifying reports related to blood transfusions. We included patient safety reports that were prepared over a 10-year period that began from the opening of the hospital. We then analyzed the causes and the corrective actions. Methods: We analyzed 125 reports related to blood transfusions, and these reports were included in the patient safety reports received from November 2008 to December 2018. The events were categorized as sampling error, inspection error, testing error, issue error, disposal error, transfusing blood components error, or others error, depending on the stage of the blood transfusion process. Regardless of the cause, the event that led to an inappropriate transfusion was classified as a transfusion incident. Results: The number of blood transfusions per year increased, and the rate of blood transfusion accidents ranged from 0.00% to 0.05% per year. A total of 125 reports were prepared over a 10-year period, and these included 8 blood sampling errors, 11 testing errors, 2 issuing errors, 94 disposal errors, 3 others errors, and 7 errors associated with the transfusing of blood components. After the transfusion incident, PDA was applied as a solution. Transfusing the wrong blood components did not occur, and the incidence of taking blood from the wrong patients was decreased. Conclusion: We applied corrective actions according to the cause of the event and we confirmed that the blood transfusion incidents decreased. (Korean J Blood Transfus 2019;30:212-218)
背景:由于输血过程的复杂性和多人参与,输血具有高风险和高错误率。本研究的目的是分享我们在输血报告分类方面的经验。我们纳入了从医院开业开始的10年间编写的患者安全报告。然后分析了原因和纠正措施。方法:我们分析了125份与输血相关的报告,这些报告纳入2008年11月至2018年12月收到的患者安全报告。这些事件被分类为抽样错误、检查错误、测试错误、发放错误、处理错误、输血成分错误或其他错误,这取决于输血过程的阶段。无论原因如何,导致不适当输血的事件被归类为输血事件。结果:年输血次数增加,输血事故率在0.00% ~ 0.05%之间。在10年期间,共编写了125份报告,其中包括8份采血错误、11份检测错误、2份发放错误、94份处理错误、3份其他错误和7份与血液成分输入有关的错误。输血事件发生后,PDA应用作为解决方案。没有发生输错血成分的情况,也降低了从错误患者身上取血的发生率。结论:根据事件发生的原因采取纠正措施,确认输血事件有所减少。(韩国输血杂志2019;30:212-218)
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引用次数: 3
A Case of Hemolytic Disease of Newborn due to Anti-Dia: Consideration of the Inclusion of Dia Antigen in Antibody Screening Test 抗Dia致新生儿溶血性疾病1例:在抗体筛选试验中纳入Dia抗原的思考
Pub Date : 2019-12-31 DOI: 10.17945/kjbt.2019.30.3.241
Han-Sol Kim, Chae-Ku Jo, Sinyoung Kim, K. Kim, M. Kim
A Case of Hemolytic Disease of Newborn due to Anti-Di: Consideration of the Inclusion of Di Antigen in Antibody Screening Test Han-Sol Kim, Chae-Ku Jo, Sin-Young Kim, Kyeong-Hee Kim, Myo-Jing Kim Department of Pediatrics, Dong-A University Hospital, Busan, Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Departments of Laboratory Medicine and Pediatrics, Dong-A University College of Medicine, Busan, Korea
新生儿抗Di溶血性疾病1例:抗体筛选试验中纳入Di抗原的考虑金汉松、赵采九、金信永、金敬姬、金明静釜山东亚大学医院儿科科、延世大学医学院检验医学科、首尔延世大学医学院检验医学科、釜山东亚大学医学院检验医学科、儿科医学科
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引用次数: 2
Molecular Genetic and Serologic Analysis of theOallele in the Korean Population 韩国人群小等位基因的分子遗传及血清学分析
Pub Date : 2019-08-31 DOI: 10.17945/kjbt.2019.30.2.124
J. Lee, S. Song, S. Oh
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引用次数: 1
Experiences of Blood Bank Performance in Brian Allgood Army Community Hospital Brian Allgood陆军社区医院血库绩效体会
Pub Date : 2019-08-31 DOI: 10.17945/kjbt.2019.30.2.174
Pil Sun Nam
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引用次数: 0
Case of D-Variant from a Frameshift MutationRHD711delC rhd711delc移码突变的d -变体一例
Pub Date : 2019-08-31 DOI: 10.17945/kjbt.2019.30.2.168
Taeo Ma, HongBi Yu, Suhak Jeon, D. Cho, S. Chun, M. Shin
D antigens are clinically significant, and routine tests on the D antigen requires the inclusion of weak D testing, which is performed using indirect antihuman immunoglobulin methods. On the other hand, exact typing of the D type of an individual can be done more precisely with RHD genotyping, which is a useful tool in cases where the RHD gene is intact. The majority of weak-D or partial-D cases are from single nucleotide changes or hybridization of RHD and RHCE genes. Nevertheless, frameshift mutations can also result in weak or partial-D. The characteristics of a frameshift mutation is typically a change in protein product after a problematic mutation and early termination of transcription, leading into truncated protein products. This paper reports a D-variant case with RHD 711delC along with a review of the relevant literature. In addition, the results of software analysis are reported. (Korean J Blood Transfus 2019;30:168-173)
D抗原具有临床意义,对D抗原的常规检测需要包括弱D检测,这是使用间接抗人免疫球蛋白方法进行的。另一方面,RHD基因分型可以更精确地对个体的D型进行准确分型,这在RHD基因完整的情况下是一个有用的工具。大多数弱d或部分d病例来自RHD和RHCE基因的单核苷酸改变或杂交。然而,移码突变也可能导致弱或部分d。移码突变的典型特征是在有问题的突变和转录的早期终止后蛋白质产物发生变化,导致蛋白质产物截短。本文报告1例d型RHD 711delC病例,并对相关文献进行复习。此外,还报告了软件分析的结果。(韩国输血杂志2019;30:168-173)
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引用次数: 4
Risk Factors for Adverse Events of Therapeutic Plasma Exchange Assessed in a Single Center Study 单中心研究评估血浆置换治疗不良事件的危险因素
Pub Date : 2019-08-31 DOI: 10.17945/kjbt.2019.30.2.148
Cheon-Gang Park, A-Jin Lee, Seon-Ho Mun, Sang-Gyung Kim, C. Jeon, H. Suh
Background: Therapeutic plasma exchange (TPE) is used to remove pathologic substances involved in various disease etiologies. The use of TPE is increasing steadily in a variety of disease. This study analyzed the incidence, type and severity of adverse events (AE) according to the initial TPE of each patient in a single center. The risk factors for AE of TPE were also elucidated. Methods: The medical and laboratory records of patients, who received TPE from January 2014 to December 2018, were reviewed retrospectively. The signs or symptoms during and after TPE were analyzed. Results: TPE sessions were performed on 95 patients. The mean age was 53.3 years and men comprised 63.2%. The most common indication for TPE was desensitization for ABO-incompatible liver transplantation (ABO-i LT) (N=56, 58.9%). A total of 27 patients (28.4%) experienced AE during the initial TPE. The types of AE were allergic reactions (N=14, 14.7%), anaphylactic reaction (N=3, 11.1%), hypotension (N=5, 5.3%), hypocalcemic reaction (N=4, 4.2%), and febrile nonhemolytic reaction (N=1, 1.1%). The severities of AE were evaluated as mild in eight procedures (8.4 %), moderate in seventeen (17.9 %), and severe in two (2.1 %). Multivariable logistic regression analysis showed that the desensitization for ABO-i LT (odds ratio (OR), 2.08; 95% CI, 1.03∼4.22) and the amount of FFP (OR, 1.07; 95% CI, 1.01∼1.09) were associated with a higher incidence of AE. Conclusion: TPE can be performed under careful patient monitoring to provide prompt intervention, particularly in patients with desensitization of ABO-i LT using FFP. (Korean J Blood Transfus 2019;30:148-155)
背景:治疗性血浆置换(TPE)是一种用于清除各种病因所涉及的病理物质的方法。TPE在各种疾病中的应用正在稳步增加。本研究根据单个中心每位患者的初始TPE分析不良事件(AE)的发生率、类型和严重程度。并对TPE发生AE的危险因素进行了分析。方法:回顾性分析2014年1月至2018年12月接受TPE的患者的医疗和实验室记录。分析TPE期间和之后的体征或症状。结果:95例患者接受TPE治疗。平均年龄为53.3岁,男性占63.2%。TPE最常见的适应症是abo血型不相容肝移植(ABO-i LT)脱敏(N=56, 58.9%)。共有27例(28.4%)患者在初始TPE时发生AE。AE的类型为过敏性反应(N=14, 14.7%)、过敏性反应(N=3, 11.1%)、低血压(N=5, 5.3%)、低钙反应(N=4, 4.2%)和发热性非溶血反应(N=1, 1.1%)。AE的严重程度分为轻度8例(8.4%),中度17例(17.9%),重度2例(2.1%)。多变量logistic回归分析显示,abo - 1 LT的脱敏性(优势比(OR), 2.08;95% CI, 1.03 ~ 4.22)和FFP的量(OR, 1.07;95% CI, 1.01 ~ 1.09)与AE的高发生率相关。结论:TPE可以在仔细的患者监测下进行,以提供及时的干预,特别是对于使用FFP治疗ABO-i LT脱敏的患者。(大韩输血杂志2019;30:148-155)
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引用次数: 0
Development of a Transfusion-Indication Data-Entry Program and Analysis of Transfusion Indications at a University Hospital in Korea 韩国某大学医院输血指征数据录入程序的开发和输血指征分析
Pub Date : 2019-08-31 DOI: 10.17945/kjbt.2019.30.2.138
W. Shin, Jeong Jae Lee, Haran Chung, J. Shin
Background: Transfusion guidelines are not only essential for the optimal use of blood products, but also help reduce transfusion-related adverse reactions and improve patients’ outcomes. In this hospital, a transfusion-indication data-entry program based on the national transfusion guidelines was developed and applied to the electronic medical record system in 2016. All transfusion orders, except for emergencies, have been performed using this program since then. This study analyzed the reasons for the transfusion to monitor the blood product usage and provide feedback to clinicians. Methods: The transfusion-indications were classified by the blood product and a pop-up window listing these indications was produced. The indications were as follows: red blood cells (RBCs) - acute blood loss, chronic anemia, surgery/procedure, transplantation and ‘other’; platelets (PLTs) - active bleeding, bleeding prophylaxis, surgery/procedure, massive transfusion, and ‘other’; fresh frozen plasma (FFP) - bleeding in coagulopathy, bleeding prophylaxis in coagulopathy, massive transfusion, plasma exchange, and ‘other’. The indications entered into the data-entry program from Sep 2016 to Feb 2018 were analyzed. Results: The most common indications for transfusion were chronic anemia for RBCs (7977/16138, 49.4%), bleeding prophylaxis for PLTs (5726/11158, 51.3%), and ‘other’ for FFP (2180/6024, 36.2%). Many clinicians entered the transfusion indication as ‘other’, but the free-text supplied by the clinician when ‘other’ was selected, often corresponded to an indication already categorized in the transfusion-indication data-entry program. Conclusion: Feedback and training on the data of transfusion indications are needed for clinicians to properly use blood products by operating the transfusion-indication data-entry program more efficiently. (Korean J Blood Transfus 2019;30:138-147)
背景:输血指南不仅对血液制品的最佳使用至关重要,而且有助于减少输血相关的不良反应并改善患者的预后。该院根据国家输血指南制定了输血指征数据录入程序,并于2016年应用于电子病历系统。从那时起,除紧急情况外,所有输血订单都使用该程序执行。本研究分析输血原因,监测血液制品使用情况,并向临床医生提供反馈。方法:按血液制品对输血指征进行分类,并以弹出式窗口列出输血指征。适应症如下:红细胞(rbc) -急性失血,慢性贫血,手术/程序,移植和“其他”;血小板——活动性出血、出血预防、手术/程序、大量输血和“其他”;新鲜冷冻血浆(FFP) -凝血功能障碍出血、凝血功能障碍出血预防、大量输血、血浆置换和“其他”。对2016年9月至2018年2月录入数据的适应症进行分析。结果:输血最常见的指征是红细胞慢性贫血(7977/16138,49.4%)、血小板预防出血(5726/11158,51.3%)和FFP“其他”(2180/6024,36.2%)。许多临床医生将输血指征输入为“其他”,但当选择“其他”时,临床医生提供的自由文本通常与输血指征数据输入程序中已经分类的指征相对应。结论:需要对输血指征数据进行反馈和培训,以便临床医生更有效地操作输血指征数据录入程序,正确使用血液制品。(大韩输血杂志2019;30:138-147)
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引用次数: 2
Alloantibodies to High-Incidence Antigen: Review of Cases and Transfusion Experiences in Korea 针对高发抗原的同种异体抗体:韩国病例和输血经验的回顾
Pub Date : 2019-08-31 DOI: 10.17945/kjbt.2019.30.2.101
S. Choi, Yoo Na Chung, D. Cho, Sinyoung Kim
Antibodies to high-incidence red blood cell antigens should be considered if panagglutination reactions are noted in all panel cells, and negative reactions to autologous red blood cells are detected on antibody screening and identification tests. In Korea, most of those antibodies are identified through international reference laboratories. To prevent a hemolytic transfusion reaction, antigen-negative red cells should be provided for those patients who have antibodies to red cell antigens. However, this is nearly impossible when the antibody has specificity to high-incidence red cell antigen. In those cases, transfusion of autologous blood, cryopreserved rare blood and the least incompatible blood components can be considered. In the case of surgery, acute normovolemic hemodilution or intraoperative blood salvage can also be considered. For the patients who have antibodies to high-incidence red cell antigens, it should be discussed to set up a national reference laboratory to quickly identify antibody specificities, and to consider establishing rare blood donor registry and frozen rare blood storage/supply system. This article reviews characteristics of antibodies to high-incidence antigens found in Koreans and also the transfusion experiences of those patients based on literature. (Korean J Blood Transfus 2019;30:101-112)
如果在所有的组细胞中都注意到泛凝集反应,并且在抗体筛选和鉴定试验中检测到对自体红细胞的阴性反应,则应考虑对高发红细胞抗原的抗体。在韩国,大部分抗体是通过国际参考实验室鉴定的。为防止溶血性输血反应,对红细胞抗原有抗体的患者应提供抗原阴性的红细胞。然而,当抗体对高发红细胞抗原具有特异性时,这几乎是不可能的。在这种情况下,可以考虑输注自体血液、冷冻保存的稀有血液和最不相容的血液成分。在手术的情况下,急性等容血液稀释或术中血液回收也可以考虑。对于有高发红细胞抗原抗体的患者,应探讨建立国家参比实验室,快速鉴定抗体特异性,并考虑建立罕见献血者登记和冷冻罕见血储存/供应系统。本文综述了韩国人高发抗原抗体的特点,并根据文献回顾了这些患者的输血经历。(大韩输血杂志2019;30:101-112)
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引用次数: 1
Erratum: Author’s order correction Comparison of the Effectiveness in the Application of Competitive and Noncompetitive Internal Control for the Laboratory Developed Polymerase Chain Reaction 在实验室开发的聚合酶链反应中应用竞争性和非竞争性内部控制的有效性比较
Pub Date : 2019-08-31 DOI: 10.17945/kjbt.2019.30.2.178
Jungwon Kang, Sunmi Shin, J. Kang, Y. I. Seo, H. Min
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引用次数: 0
Investigation of the Association of HCV or HIV Markers in Non-Discriminated Blood Donations 非歧视性献血中HCV或HIV标记物相关性的调查
Pub Date : 2019-08-31 DOI: 10.17945/kjbt.2019.30.2.163
Jungwon Kang, Sunmi Shin, J. Kang, Y. I. Seo, H. Min, Myunghan Kim
HBV core antibody and surface antibody test are currently conducted for those donors showing non-discriminated reactive (NDR) results on a nucleic acid amplification test (NAT) as a blood donor screening assay. It is necessary to investigate the relationship with HCV or HIV in the donors showing NDR results. From June 12th, 2012 to December 31st, 2018, 0.05% (9,020/17,798,461) donors showed NDR results on a NAT. Among the donors showing NDR results, 17 and 18 donors showed positive results on serological assay of HCV and HIV, respectively. 23 donors with NDR results showed positive results on the serological assay or NAT for HCV or HIV on the following donation. Further study and more accumulated data are required because it may be difficult to find the cause of NDR results by the current serological assay that is used for screening blood donors. (Korean J Blood Transfus 2019;30:163-167)
目前,对核酸扩增试验(NAT)无区分反应(NDR)结果的献血者进行HBV核心抗体和表面抗体检测,作为献血者筛选试验。有必要调查显示NDR结果的献血者与HCV或HIV的关系。2012年6月12日至2018年12月31日,0.05%(9020 / 17798,461)献血者在NAT检测中显示NDR,其中HCV血清学检测阳性17例,HIV血清学检测阳性18例。有NDR结果的23名献血者在随后的捐赠中HCV或HIV血清学检测或NAT结果呈阳性。由于目前用于筛查献血者的血清学检测可能难以发现NDR结果的原因,因此需要进一步的研究和更多的积累数据。(大韩输血杂志2019;30:163-167)
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引用次数: 0
期刊
The Korean Journal of Blood Transfusion
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