SHOT Annual Report 2009 - Serious Hazards of Transfusion

More documents

Recommendations

Info

20. Paediatric Cases Definition Paediatric cases comprise all those occurring in patients under 18 years of age. Paediatric cases 2009 This chapter analyses the data on paediatric cases from the other chapters in this annual report. All the cases are also included in the data in their respective chapters. All children < 18 years of age are included and have been subdivided by age groups – neonates ≤ 28 days; infants > 4 weeks and < 1 year old; and children < 16 years – because each of these has recommendations regarding blood components. The chapter particularly highlights the cases related to the age of the patient. Table 46 Summary of paediatric cases 2009 Category of case No. ≤ 4 wks No. > 4 wks – < 1 yr No. 1 – < 16 yrs No. 16 – < 18 yrs Total paediatric cases IBCT 7 9 21 3 40 Administration 4 1 0 0 5 Lab error 1 4 4 1 10 SRNM (total) Irrad/CMV negative MB-FFP requirement (or SD-FFP) Others 2 2 0 0 4 3 1 0 17 7 6 4 2 2 0 0 25 14 7 4 WBIT 0 0 0 0 0 Handling and Storage 6 0 2 1 9 Inappropriate & unnecessary 4 2 7 2 15 Anti-D related 0 0 0 3 3 ATR 2 3 28 4 37 HTR 0 0 2 0 2 TACO 0 0 0 0 0 TRALI 0 0 0 2 2 PTP 0 0 0 0 0 TA-GvHD 0 0 0 0 0 TTI 0 1 0 0 1 Autologous (cell salvage) 0 0 0 1 1 TOTAL 19 15 60 16 110 140 20. Paediatric Cases
Introduction and overall trends In 2009, 110 of the total 1279 reports (8.6%) involved patients < 18 years (yr). Furthermore, 94/1279 (7.3%) reports were in children < 16 yr, 34/1279 (2.7%) in infants < 1 yr, and 19/1279 (1.5%) in neonates ≤ 4 weeks. Although this represented an increase in the total number of paediatric reports compared with previously, it mirrors the overall increase in reports; the proportions in different age groups are similar to those in 2008. Thirty-four (31%) of paediatric reports were from infants < 1yr of age, of whom 19/34 (56%) were neonates ≤ 4 weeks old. As discussed previously, there is a disproportionally high number of reports in children compared with adults (see SHOT 2008 for further discussion of paediatric reporting trends). As before, the majority of paediatric reports were error related (IBCT, handling and storage, inappropriate and unnecessary), comprising 64/110 (58%) reports. For the infant age group, error reports are a higher proportion, with 28/34 (82%) this year. This compares with the adult figure of 570/1279 (45%). The factors leading to many types of errors are the same in adults and children. However, some factors may be more likely to occur in the paediatric age group, including those that are unique to these patients such as age-related special component requirements. Reports involving these factors are described as ‘paediatric-related’ in the chapter, and this year were estimated to be 35/64 (55%) of all paediatric error reports with a higher proportion in the infant age group, at 23/28 (82%). ATR cases followed the trend established in 2008, with 37/110 (34%) paediatric cases, an increase in total cases from the 25 reported last year. Figure 23 Number of paediatric cases in each reporting category For the error reports, the proportion of ‘paediatric-related’ cases is also illustrated 40 35 Key Total number of Paediatric Cases Number of cases 30 25 20 15 ‘Paediatric-related’ Cases 10 5 0 IBCT Admin IBCT Lab error IBCT SRNM IBCT WBIT I&U HSE Anti–D related Category ATR HTR TRALI TACO PTP TA-GvHD TTI Autologous 20. Paediatric Cases 141
Page 1 and 2:
Annual Report 2009 Affiliated to th
Page 3 and 4:
Requests for further information sh
Page 5 and 6:
1. Foreword The Serious Hazards of
Page 7 and 8:
2. SHOT - The UK Haemovigilance Sch
Page 9 and 10:
3. Participation in Haemovigilance
Page 11 and 12:
Figure 2 Number of reports sent per
Page 13 and 14:
For the first time this year, SHOT
Page 15 and 16:
4. SHOT 2009-2010 UK Transfusion La
Page 17 and 18:
Update on 2008 recommendations Last
Page 19 and 20:
Numbers of components issued In 200
Page 21 and 22:
Table 10 Cumulative mortality/morbi
Page 23 and 24:
Acute transfusion reaction (ATR) Th
Page 25 and 26:
6. Key Messages and Main Recommenda
Page 27 and 28:
Recommendation All pulmonary compli
Page 29 and 30:
2005 Appropriate use of blood compo
Page 31 and 32:
7. Incorrect Blood Component Transf
Page 33 and 34:
Table 12 Summary of IBCT cases Type
Page 35 and 36:
Major morbidity There were 2 cases
Page 37 and 38:
Wrong blood components transfused t
Page 39 and 40:
Learning points ■■ All componen
Page 41 and 42:
Table 15 Number of staff involved i
Page 43 and 44:
All of the errors in this group wer
Page 45 and 46:
Trust and sometimes in separate Tru
Page 47 and 48:
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 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 and 140: The most likely source of the organ
Page 141 and 142: 19. Autologous Transfusion Definiti
Page 143: RECOMMENDATIONS There are no new re
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
show all

SHOT Annual Report 2009 - Serious Hazards of Transfusion

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?