Transfusion reactions
Performance Measure Protocol
Transfusion reactions
Purpose and Rationale:
A transfusion reaction is a serious problem occurring after a blood transfusion where a
patient’s own immune system destroys the transfused blood cells. The risk of adverse
outcome from erroneous transfusion rivals or exceeds current estimates of the risk of
acquiring infectious disease by transfusion1,2.
Studies have shown transfusion reactions to be very rare3,4, and many modern laboratory
methods and safeguards are in place to prevent this medical error. However, due to the
serious nature of these events, expert panels at the Agency for Healthcare Research and
Quality (AHRQ) and the Organization for Economic Co-operation and Development (OECD)
continue to favour the use of transfusion reactions as an important patient safety
measure1,5.
Description and Type:
Rate-based performance indicator.
•
Transfusion reactions
Definition:
Numerator: Client discharges with a diagnosis of transfusion reaction.
Exclude cases:
•
Where diagnosis of transfusion reaction is present upon admission.
Note: For organizations using ICD-9-CM codes, transfusion reaction diagnosis codes are
as follows:
•
999.6 ABO incompatibility reaction
•
999.7 Rh incompatibility reaction
•
999.8 Other infusion and transfusion reaction
•
E8760 mismatched blood in transfusion
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Transfusion reactions
Accreditation Canada International
For organizations using ICD-10-CM codes, transfusion reaction diagnosis codes are T80.
Denominator: All transfusions within the specified measurement period.
Exclude cases:
•
Where diagnosis of transfusion reaction is present upon admission.
Data Collection:
Data must be collected for each quarter and submitted to Accreditation Canada on an
annual basis. Data for the past 4 quarters (last quarter ending March 31st) is to be submitted
on May 31st of each year.
Limitations and Considerations:
This indicator includes only transfusion reactions that require medical care. Some minor
reactions that do not require medical care may be missed, although expert panels agree
that these minor reactions are not likely a result of medical error. The transfusion reactions
measure is influenced by the reliability of coding, and therefore may not be comparable
across organizations.
References:
1.
Millar J, Mattke Soeren, et al. Selecting Indicators for Patient Safety at the Health
Systems Level in OECD Countries. Paris, France. OECD Health Technical Papers
No. 18; 2004.
2.
Linden JV, Wagner K, Voytovich AE, Sheehan J. Transfusion errors in New York
State: an analysis of 10 year’s experience. Transfusion 2000; Vol 40:1207-13.
3.
McDonald K, Romano P, Geppert J, et al. Measures of Patient Safety Based on
Hospital Administrative Data - The Patient Safety Indicators. Technical Review 5
(Prepared by the University of California San Francisco - Stanford Evidence-based
Practice Center under Contract No. 290-97-0013). AHRQ Publication No. 02-0038.
Rockville, MD: Agency for Healthcare Research and Quality. August 2002.
4.
Rosen AK, Rivard P, Zhao S, Loveland S, Tsilimingras D, Christiansen CL, et al.
Evaluating the patient safety indicators: how well do they perform on Veterans
Health Administration data? Med Care 2005 Sep;43(9):873-84.
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Transfusion reactions
Accreditation Canada International
5.
Patient Safety Indicators Download. AHRQ Quality Indicators – Guide to Patient
Safety Indicators. March 2007. Agency for Healthcare Research and Quality,
Rockville, MD. http://www.qualityindicators.ahrq.gov/psi_downl
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Transfusion reactions
Accreditation Canada International