Transfusion error surveillance system (TESS), 2017-2019
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- Organization: Health Canada
- Date published: September 2022
TESS project
To improve transfusion processes and patient safety, TESS captures non-nominal data regarding errors that occurred at any point in the transfusion chainFootnote 1
This project was initiated in 2005. The Transfusion Error Surveillance System (TESS):2012-2016 report contains a detailed methodology of TESS
Four jurisdictions participating in TESS monitor 16% of national blood transfusion activities in Canada
Surveillance data summary
30,157 errorsFootnote 2 (e.g. blood sample labelled with incorrect patient identification) were reported during 2017-2019
0.1% of all reported errors resulted in harmFootnote 3 to the patient
Text Description - Overall counts of reported errors for 2017-2019
All Errors: 30,157 (100%)
- Near Miss: 29,095 (96.5%)
- Planned Discovery: 28,824 (95.6%)
- Unplanned Discovery: 271 (0.9%)
- Actual Event: 1,062 (3.5%)
- Harm: 23 (0.1%)
- No Harm: 1,039 (3.4%)
Text Description - Location of error occurrence
| Location | Number of errors (n) | Percentage (%) |
|---|---|---|
| Emergency | 4,384 | 14 |
| ICU | 2,610 | 9 |
| Medical/surgical ward | 5,684 | 19 |
| Obstetrics | 933 | 3 |
| Operating room | 2,604 | 9 |
| Outpatient clinics and procedures | 4,056 | 13 |
| Others | 480 | 2 |
| Transfusion laboratory | 9,406 | 31 |
Text Description - Harm caused by errors
| Type of Harm | Number of Harm (n) | Percentage (%) |
|---|---|---|
| TACOFootnote 5 | 15 | 65.2 |
| OthersFootnote 6 | 8 | 34.8 |
Reporting and investigating errors in both transfusion services and clinical settings help identify and control risks before resulting in harm to the patient, thus providing valuable opportunities to improves transfusion safety
Learn more about TESS
More information on the Blood Safety Contribution Program web page