SHOT Annual Report 2009 - Serious Hazards of Transfusion

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Recommendations still active from previous years, with modifications Year first made Recommendation Target Progress 2008 Staff must maintain a high index of suspicion of bacterial causes when managing acute transfusion reactions. Symptoms may appear to be allergic in nature, but cultures must still be performed whenever bacterial contamination is a possibility. Hospital transfusion teams A BCSH guideline on the management of acute transfusion reactions is in preparation. 2005, 2008, 2009 Where bacterial contamination is suspected, staff should report the incident to the blood services as soon as possible in order to facilitate the return of implicated packs and the recall of any associated units. Attention should be paid to the sampling and storage of implicated units or their residues to avoid environmental contamination of the pack. Hospital transfusion teams, UK blood services Guidance for English hospitals can be found on the NHSBT hospitals website: http://www.blood.co.uk/hospitals/ library/request_forms/aer/ For other services please discuss with the local blood supply centre. 2003, 2008 Strategies to reduce bacterial contamination of blood components should continually be reviewed. These include: - Diversion of the first 20–30 mL of the donation (likely to contain any organisms entering the collection needle from the venepuncture site) - Enhanced donor arm cleansing using chlorhexidene - Consideration of bacterial screening interventions and/or pathogen inactivation - Adherence to BCSH guidelines (2009) with regard to the visual inspection of blood components for any irregular appearance immediately prior to transfusion. UK blood services, SaBTO, blood collection teams, hospital transfusion laboratories, staff undertaking pretransfusion bedside checking UK blood services have introduced enhanced donor arm cleansing and continue to monitor and evaluate the success of all possible interventions, such as bacterial screening and/or pathogen inactivation. 2003 Hospitals should continue to report all possible incidents of post-transfusion infection via appropriate local and national reporting routes. Hospital transfusion teams Serious Adverse Reactions must be reported under the terms of the BSQR 2005. Reporting to SHOT is required for compliance with HSC/2002/009 ‘Better Blood Transfusion’ and is a standard for the Clinical Negligence Scheme for Trusts in England. 136 18. Transfusion-Transmitted Infection (TTI)
19. Autologous Transfusion Definition Any adverse event or reaction associated with autologous transfusion including intraoperative and postoperative cell salvage (washed or unwashed), acute normovolaemic haemodilution or preoperative autologous donation. DATA SUMMARY Total number of cases 14 Implicated components Mortality/morbidity Autologous Red cells 14 Deaths due to transfusion 0 FFP Deaths in which reaction was implicated Platelets Major morbidity 0 0 Gender Age Emergency vs. routine and core hours vs. out of core hours Where transfusion took place Male Female Unknown 5 2 7 18 years+ 16 years+ to 18 years 1 year+ to 16 years 28 days+ to 1 year Birth to 28 days Total 13 1 0 0 0 14 Emergency Routine Not known In core hours Out of core hours Not known/applicable 2 11 1 5 1 8 ED Theatre + ITU/NNU/ HDU/Recovery Wards Community Other Not known 6 8 Fourteen questionnaires were received; none was withdrawn or transferred to another section and 7 were transferred in from other categories. This section describes the main findings from 14 completed questionnaires. There were no reports submitted during this reporting period relating to adverse events while undertaking acute normovolaemic haemodilution (ANH) or preoperative autologous donation (PAD). Both these techniques are rarely undertaken and their use is not routinely recommended. There is a reduction in the number of reports compared with last year (2008) when a pilot was undertaken as a joint initiative between SHOT and the UK Cell Salvage Action Group. However, cell salvage adverse events are now part of the SHOT system and as such should be reported through the new online reporting system. Adverse events by specialty Orthopaedic – 10 events; general surgery – 2 events; urology – 1 event; obstetrics – 1 event. Adverse events by type of autologous transfusion Intraoperative cell salvage (ICS) – 6; postoperative cell salvage (PCS) – 8. PCS incidents n = 8 ■■ ■■ ■■ ■■ 1 system not assembled correctly 1 wrong infusion set used 5 pyrexia, rigor or bradycardia 1 excessive time to transfuse 19. Autologous Transfusion 137
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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
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multiple group O components; 1 grou
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Learning points ■■ ■■ Where
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Three interpretation errors occurre
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IT must be used to its full potenti
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Case 8 When the laboratory knows of
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■■ All staff must take full pro
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7.1 Errors Relating to IT Systems (
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to laboratory B. The clinical reque
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Improving Laboratory Standards (bas
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7.2 Right Blood Right Patient (RBRP
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COMMENTARY Each year SHOT emphasise
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Core hours vs. out of hours and Whe
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Broad breakdown of where primary er
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Case 6 Dilute (possible drip arm) s
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Case 10 Over-transfusion following
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9. Handling and Storage Errors (HSE
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Excessive time to complete administ
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etween removing the component from
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10. Adverse Events Relating to Anti
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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 and 100: Bacterial culture of patient and un
Page 101 and 102: Previous recommendations that are s
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: The most likely source of the organ
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
Page 151 and 152: always require notification by clin
Page 153 and 154: 21. Near Miss Reporting Definition
Page 155 and 156: 29 UK Resuscitation Council Emergen
Page 157: 24. Acknowledgements The Steering G
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SHOT Annual Report 2009 - Serious Hazards of Transfusion

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