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BACKGROUND: Tracking transfusion reactions is essential to improve patient safety. Under-reporting of transfusion reactions was suspected in our institution. To evaluate this phenomenon, we followed an active surveillance protocol for transfusion reactions for 3 months in 2016 and compared transfusion reaction rates during that period with 2015 and 2017. METHODS: The study was carried out in a tertiary care hospital over 3 months in 2016. Investigators visited hospital units and collected data on all patients who received a transfusion in the preceding 24 h. Further details were obtained about all cases that are suspected to have had a transfusion reaction. Transfusion reactions were defined according to the definitions provided by National Healthcare Safety Network Biovigilance Component Hemovigilance Module Surveillance Protocol 2016. Rates that were obtained through active surveillance were compared through appropriate statistical methods with transfusion reaction rates obtained through passive reporting from 2015 and 2017. RESULTS: During the study period, a total of 47 transfusion reactions were captured through active surveillance and passive reporting (transfusion reaction rate 0.79%). There was a statistically significant difference between these rates in comparison with rates detected in similar months from 2015 (0.26%) and 2017 (0.17%). CONCLUSIONS: Active surveillance for transfusion reactions is an effective method for improving rates of the detection of suspected transfusion reactions. The phenomenon of under-reporting of transfusion reactions requires thorough evaluation by transfusion medicine professionals to introduce targeted solutions and improve reporting rates.