SHOT Annual Report 2009 - Serious Hazards of Transfusion

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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
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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
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Anti-D Ig given to the wrong patien
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RECOMMENDATIONS New recommendations
Page 93 and 94: Case 1 Possible fatal reaction A ma
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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
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SHOT Annual Report 2009 - Serious Hazards of Transfusion

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