Sample collection and sample handling errors submitted to the transfusion error surveillance system, 2006 to 2015.

BACKGROUND: In Canada, transfusion-related errors are voluntarily reported to a tracking system with the goal to systematically improve transfusion safety. This report provides an analysis of sample collection (SC) and sample handling (SH) errors from this national error-tracking system. STUDY DESIGN AND METHODS: Errors from 2006 to 2015 from 23 participating sites were extracted. A survey was conducted to obtain information regarding institutional policies. Samples received in the blood bank were used to calculate rates. "Wrong blood in tube" (WBIT) errors are blood taken from wrong patient and labeled with intended patient's information, or blood taken from intended patient but labeled with another patient's information. RESULTS: A total of 42,363 SC and 14,666 SH errors were reported. Predefined low-severity (low potential for harm) and high-severity errors (potential for fatal outcomes) increased from 2006 to 2015 (low SC, SH: 13-27, 3-12 per 1000; high SC, SH: 1.9-3.7, 0.5-2.0 per 1000). The WBIT rate decreased from 12 to 5.8 per 10,000 between 2006 and 2015 (p < 0.0001). The overall WBIT rate was 6.2 per 10,000, with variability by site (median, 0.3 per 10,000; range, 0-17 per 10,000). Sites with error detection mechanisms, such as regrouping second sample requirements, had lower error rates than sites that did not (SC, SH: 12, 1 per 1000 samples vs. 17, 3 per 1000 samples; p < 0.0001). CONCLUSION: WBIT rates decreased significantly. Low-severity error rates are climbing likely due to increased ascertainment and reporting. Prevention studies are necessary to inform changes to blood transfusion standards to eliminate these errors.

Clinical characteristics of pediatric patients hospitalized with methicillin-resistant Staphylococcus aureus in Canadian hospitals from 2008 to 2010.

Methicillin-resistant Staphylococcus aureus (MRSA) infections were uncommon in children in Canada until the 1990s. Using a standardized case report form, treating physicians reported children hospitalized due to MRSA infections in Canadian hospitals through the Canadian Pediatric Surveillance Program in a 24-month period (2008 to 2010). Of 155 cases reported, 70% were ≤4 years of age and approximately one-third had an underlying medical condition. The most common clinical infections involved skin and soft tissue (69%), the lower respiratory tract (12%), and bone and joint (10%). Almost one-third had had contact with the health care environment in the previous year and 18% had a known household member with MRSA. Initial therapy with a beta-lactam alone occurred in 65%, while 22% included vancomycin. No child in this cohort died but 14% required admission to the intensive care unit. Of 143 reports of individual isolates, 93% were reported susceptible to trimethoprim-sulfamethoxazole, 63% to clindamycin and 50% to mupirocin. The present study involved only children hospitalized with MRSA infections. It may not be representative of the children treated as outpatients nor children in selected areas of Canada where MRSA infections may be more endemic. Further targeted surveillance to identify risks and treatment practices in these populations may be important.

Jusque dans les années 1990, l'infection par le staphylocoque doré méthicillinorésistant (SARM) était peu courante chez les enfants du Canada. Au moyen d'un formulaire de déclaration de cas standardisé, des médecins traitants ont signalé les enfants hospitalisés à cause d'une infection par le SARM dans les hôpitaux canadiens par l'entremise du Programme canadien de surveillance pédiatrique au cours d'une période de 24 mois (2008 à 2010). Des 155 cas déclarés, 70 % avaient quatre ans ou moins, et environ le tiers présentait un problème de santé sous-jacent. Les infections cliniques les plus courantes touchaient la peau et les tissus mous (69 %), les voies respiratoires inférieures (12 %) ainsi que les os et les articulations (10 %). Près du tiers avait eu des contacts avec le milieu de la santé au cours de l'année précédente, et dans 18 % des cas, un membre de la famille était atteint d'une SARM connue. Chez 65 % des patients, le traitement initial se limitait à une bêta-lactamine, tandis que dans 22 % des cas, il incluait la vancomycine. Aucun enfant de cette cohorte n'est décédé, mais 14 % ont dû être hospitalisés aux soins intensifs. Des 143 déclarations d'isolats individuels, on a signalé que 93 % étaient susceptibles au triméthoprim-sulfaméthoxazole, 63 % à la clin-damycine et 50 % à la mupirocine.La présente étude portait seulement sur les enfants hospitalisés à cause d'une infection par le SARM. Elle n'est peut-être pas représentative des enfants traités en consultations externes ou des enfants de certaines régions du Canada où les infections par le SARM sont peut-être plus endémiques. Il serait peut-être important de poursuivre une surveillance ciblée pour déterminer les risques et les pratiques thérapeutiques au sein de ces populations.