SHOT Annual Report 2009 - Serious Hazards of Transfusion

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Reporting of ATRs Forty-nine cases were reported to SHOT only, and not to the MHRA. In 4 cases patients appeared to have experienced minor morbidity as their hospital stay had been prolonged, and these reactions should have been reported to MHRA. 34 The majority of cases (292) were discussed at the HTC, and this resulted in new local recommendations in 17 instances. Recommendations included: improvement to adverse incident reporting, management plans for a particular patient, and plans to improve training, monitoring, patient assessment or investigation. In 1 case, reinforcement of the hospital’s warfarin reversal policy was advised. COMMENTARY ■■ ■■ The number of acute transfusion reactions reported has increased further this year. This is mainly accounted for by increased numbers of febrile or allergic reactions, as anaphylactic and hypotensive reactions have not increased, and this is likely to be due to better reporting practice. Haemovigilance plays an important role in collating information on acute transfusion reactions for which the causes are not well understood, e.g. isolated hypotension. Continued reporting of such cases is valuable so that patterns and causations may be identified. RECOMMENDATIONS New recommendations ■■ All moderate and severe transfusion reactions should have investigations performed. Core investigations should include full blood count, U&E, LFT, repeat group and screen, and urinalysis. Additional investigations should be performed as dictated by the patient’s symptoms. Bacterial culture of the patient and unit should be performed if TTI is thought to be a possibility. In such cases, a blood service consultant should be contacted for consideration of recall of associated components from the implicated donation. Action: HTCs, HTTs ■■ IgA should be measured in all patients who experience severe allergic or anaphylactic reactions. Measurement of IgA will help assess the relevance of IgA deficiency, and has clinical relevance for the patient, as it may indicate part of the spectrum of common variable immunodeficiency. 33 Action: HTCs, HTTs 96 11. Acute Transfusion Reactions (ATR)
Previous recommendations that are still current Year first made Recommendation Target Progress 2008 It cannot be assumed that all adverse reactions to blood or products are due to an ATR as currently defined in this chapter. Unless the diagnosis is clear, patients whose reactions are moderate or severe* should be fully investigated, with a view to identifying other potentially serious causes of the symptoms such as TRALI, bacterial contamination, TACO or haemolysis. In addition, it should be borne in mind that symptoms may be due to the patient’s underlying condition or other intercurrent illness. Hospitals should have a policy for the investigation and management of ATRs, based on current best practice. An update of BCSH guidelines is in progress. * Previously this recommendation read: ‘… reactions severe enough to warrant stopping’. However, a review of reports indicates that in nearly all such cases transfusions are discontinued. HTCs, HTTs BCSH guidelines in preparation will stress the importance of recognising and managing symptoms. 2008 As the mechanism of ATR is still not clear, the role of unselected testing for HLA, HPA or HNA antibodies appears very limited. 32 Patients who experience anaphylactic or severe allergic reactions after platelets should have an increment measured between 1 and 24 hours after transfusion. A severe reaction could indicate platelet refractoriness, in which case HLA testing is indicated. Otherwise, for severe allergic reactions without refractoriness, the next step should be a trial of PAS-suspended platelets, or washed components, before embarking on HLA testing. HTCs, HTTs This will be stressed in the forthcoming BCSH guideline. 2006 Serious transfusion reactions can occur at any stage during the transfusion, emphasising the need to keep all patients visible and accessible to nursing staff. HTTs The National Comparative Audit of Overnight Transfusion has added to the evidence that overnight transfusions need to be monitored as closely as those carried out during the daytime. 11. Acute Transfusion Reactions (ATR) 97
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Annual Report 2009 Affiliated to th
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Requests for further information sh
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1. Foreword The Serious Hazards of
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2. SHOT - The UK Haemovigilance Sch
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3. Participation in Haemovigilance
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Figure 2 Number of reports sent per
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For the first time this year, SHOT
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4. SHOT 2009-2010 UK Transfusion La
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Update on 2008 recommendations Last
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Numbers of components issued In 200
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Table 10 Cumulative mortality/morbi
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Acute transfusion reaction (ATR) Th
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6. Key Messages and Main Recommenda
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Recommendation All pulmonary compli
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2005 Appropriate use of blood compo
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7. Incorrect Blood Component Transf
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Table 12 Summary of IBCT cases Type
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Major morbidity There were 2 cases
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Wrong blood components transfused t
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Learning points ■■ All componen
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Table 15 Number of staff involved i
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All of the errors in this group wer
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Trust and sometimes in separate Tru
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IBCT events originating in the hosp
Page 49 and 50: multiple group O components; 1 grou
Page 51 and 52: Learning points ■■ ■■ Where
Page 53 and 54: Three interpretation errors occurre
Page 55 and 56: IT must be used to its full potenti
Page 57 and 58: Case 8 When the laboratory knows of
Page 59 and 60: ■■ All staff must take full pro
Page 61 and 62: 7.1 Errors Relating to IT Systems (
Page 63 and 64: to laboratory B. The clinical reque
Page 65 and 66: Improving Laboratory Standards (bas
Page 67 and 68: 7.2 Right Blood Right Patient (RBRP
Page 69 and 70: COMMENTARY Each year SHOT emphasise
Page 71 and 72: Core hours vs. out of hours and Whe
Page 73 and 74: Broad breakdown of where primary er
Page 75 and 76: Case 6 Dilute (possible drip arm) s
Page 77 and 78: Case 10 Over-transfusion following
Page 79 and 80: 9. Handling and Storage Errors (HSE
Page 81 and 82: Excessive time to complete administ
Page 83 and 84: etween removing the component from
Page 85 and 86: 10. Adverse Events Relating to Anti
Page 87 and 88: Omission or late administration of
Page 89 and 90: Anti-D Ig given to the wrong patien
Page 91 and 92: RECOMMENDATIONS New recommendations
Page 93 and 94: Case 1 Possible fatal reaction A ma
Page 95 and 96: adequate resources both for monitor
Page 97 and 98: Figure 12 Reaction by component typ
Page 99: Bacterial culture of patient and un
Page 103 and 104: Figure 13 Number of cases of HTR re
Page 105 and 106: Antibody only detectable in eluate
Page 107 and 108: Table 39 Serology, laboratory signs
Page 109 and 110: Table 40 DHTRs - New specificities
Page 111 and 112: 13. Transfusion-Related Acute Lung
Page 113 and 114: Classification of cases according t
Page 115 and 116: Comparative data on implicated comp
Page 117 and 118: Case Histories TRALI probable Case
Page 119 and 120: RECOMMENDATIONS New recommendations
Page 121 and 122: Table 42 Cases classified according
Page 123 and 124: Clinical details and transfused flu
Page 125 and 126: Cases in which RBC transfusion was
Page 127 and 128: exchange in patients with TTP. 43 I
Page 129 and 130: 15. Transfusion-Associated Dyspnoea
Page 131 and 132: 16. Post-Transfusion Purpura (PTP)
Page 133 and 134: ■■ The requirement to irradiate
Page 135 and 136: Two incidents (both bacterial, desc
Page 137 and 138: Viral and parasitic TTIs Since 1996
Page 139 and 140: The most likely source of the organ
Page 141 and 142: 19. Autologous Transfusion Definiti
Page 143 and 144: RECOMMENDATIONS There are no new re
Page 145 and 146: Introduction and overall trends In
Page 147 and 148: incident group O D negative units w
Page 149 and 150: Table 47 Types of reactions for eac
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always require notification by clin
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21. Near Miss Reporting Definition
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29 UK Resuscitation Council Emergen
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24. Acknowledgements The Steering G
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SHOT Annual Report 2009 - Serious Hazards of Transfusion

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