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Oral Abstract

Quality

Oral Abstract Session - Non-Infectious Hazards of Blood Transfusion

#OA3-AM25-SN-09 - Transfusion Safety: A Journey of Establishing Risk Register to Standardized Hemovigilance in a LMIC Healthcare Setting

Sunday, October 26, 2025
2:30 PM - 3:30 PM  PT
Room: SDCC 30AB
CE: N/A
Oral Abstracts
Background/Case Studies:

Safe blood transfusion is a complex process that requires coordination among various hospital services which carries various risks. Historically transfusion safety has been the focus of the global health community. In LMICs, unique challenges increase blood transfusion risks due to resource and infrastructure limitations, variable training, and difficulties in standardized procedures. Recognizing this, Indus Hospital & Health Network IHHN- Karachi Pakistan took Initiative of organizational risk register for standardize Hemovigilance (HV) from January 2022-2023 which is also in aligning with AABB standards and focusing on sustainable solutions, aims to strengthen Quality Management System (QMS) and improve patient safety.


Study

Design/Methods: A cross-sectional study design was conducted at IHHN Regional Blood Center-Karachi of risk identification followed by a comprehensive assessment of likelihood and impact and strategize the mitigation measures through risk assessment tool and risk matrix. The risk register  was used across the blood center operations (donor collection to transfusion)

Results/Findings:



























Risk Identification Findings  



 













The 2022-2023 Risk Register identified 14 key risks, with 'Hemolytic Transfusion Reaction' and 'Transmission of TTI' being significant concerns. However, risk register 2024-2025 shows an increase in risks from 14 during 2022-2023 to 18 during included 'bacterial contamination' and 'deranged blood product temperatures from blood donation drives, reflecting proactive responses. 'Wrong patient/donor blood group' remained high priority 













Risk Assessment Outcomes  







Overall risk ratings comparison of fiscal year 2022-2023 till now showed declined trend. For instance, patient identification mismatch on sample (manual label) and electronic request shifted from 'High risk level of 15 to Medium risk level of (5) in 2025 by use of Printed label sample. Another instance where Staff burnout risk level dropped from 9 to 6 with use of Advance Controls like transition from manual work to automation and workload ratio balancing  













Risk Mitigation Effectiveness 







Primary strategies included Training, Close monitoring, SOP implementation, and Engineering controls. Enhanced Process monitoring. Eliminated risk of out-of-range temperature blood products. Maintaining DI water TDS value required spare parts and 'end-user log sheet monitoring' to mitigate 'wrong TTI results' and 'equipment damage. 






Conclusions: This study demonstrates the successful establishment of a structured risk register, evolving into standardized hemovigilance by systematically identifying, assessing, and mitigating risks, IHHN's Blood Center has achieved tangible improvements in transfusion safety through prioritizing practical, sustainable solutions aligned with international standards and bolstering confidence in LMIC blood transfusion services