WASHINGTON, DC—The CDC hopes to bolster patient safety through the recent introduction of its new Hemovigilance Module.

The new system will monitor adverse events in patients who receive blood transfusions and is part of its National Healthcare Safe

ty Network (NHSN) — a voluntary, secure, internet-based surveillance system that integrates patient and healthcare personnel

safety surveillance systems.

Hospitals that choose to participate in the Hemovigilance Module will be able to submit blood transfusion-related data confidentially to CDC. In collaboration with AABB and other partners, CDC will be able to review the data to help identify ways to improve the safety of blood transfusions. “The development of this goes back to approximately 2006 when we realized we were one of the only developed countries in the world to not have a hemovigilance system,” stated Matthew J Kuehnert, MD, director of the CDC’s Office of Blood, Organ, and Other Tissue Safety.

He noted that there is a need for the system because while blood used in transfusions in the US is “as safe as it has ever been,” there is still a risk posed in getting a blood transfusion. “It’s important to understand that transfusion safety is public health, just like patient safety overall in the hospital is public health.”

Blood Transfusion Safety

Kuehnert said that data indicates that as many as 1% of all transfusions can result in a reaction to a patient. While most are mild reactions such as hives or itching, other reactions are more serious and can result in fatalities.

In addition,errors such as a patient accidentally receiving the wrong blood type can occur during a blood transfusion. Incidents in hospitals are fairly common. “There are all sorts of opportunities in the course, ranging from receiving a unit to actually transfusing a unit into a patient where something can go wrong.”

Hospitals already have quality control for transfusions, but the new opportunity for hospitals joining the Hemovigilance Module will be to be able to compare the types and the rates of adverse blood transfusion events that the hospital is experiencing with those of other facilities.

Kuehnert noted that the Hemovigilance Module is a confidential system. “We will never tell anyone whether a facility is participating or not. If a facility wants to tell the world that they are participating that is fine, but it is their choice. They can’t tell which other facilities are [participating] either. Being voluntary, it puts the impetus on us to make the system useful. Since facilitites don’t have to participate, the system has to be valuable on its own merit.”

Monitoring Blood

Kuehnert said that this new public health surveillance system is a first of its kind to focus on blood. While the FDA regulates blood and has reporting systems in place to determine whether rules were broken or procedures were not followed, the CDC system will use its data to analyze the events and determine how they can be prevented. “We are just looking at any problem that may have led to an interruption in the quality control process.”

Data reflecting commonly detected problems will allow CDC and the transfusion community to determine whether a national intervention is needed.

All medical facilities, including federal facilities, are invited to participate in the system. CDC provides the module at no cost to hospitals and healthcare facilities. The agency also provides participating facilities with training and ongoing user support. Hospitals interested in participating can visit www.cdc.gov/nhsn.

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