SHOT Annual Report 2009 - Serious Hazards of Transfusion

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Recommendations still active from previous years Year first made Recommendation Target Progress 2008 The trend in increasing ATR cases, in particular in relation to platelets, needs careful monitoring. SHOT This year there was a similar proportion of paediatric ATR cases, but the number of platelet cases was stable, and fewer than cases involving red cells. 2008 Clinical staff should be encouraged to report all ward-based reactions and events including possible TACO and TRALI and neonatal ATR cases. HTTs There has been little change in reporting patterns, and without a prospective clinical study it may be difficult to capture these cases. The need for clinicians to be alert to transfusion reactions has been illustrated by the 2009 paediatric TTI report. 2007 Laboratory BMSs must be aware of special component requirements in patients under 16, and routine checking for additional flags should be carried out based on the date of birth. HTT, hospital transfusion laboratories and consultant haematologists with responsibility for transfusion This recommendation continues to need emphasis in 2009, and laboratories need sufficient manpower and IT support. Laboratories must also demand that they are given requests for paediatric transfusions in mL and not units. 2007 Prescribing for paediatric patients should be carried out only by those with appropriate knowledge and expertise in calculating dosage and administration rates for this group. HTT and clinical users of blood The 2009 report demonstrates a need for continuing training in this area. 2007 Special requirements are more common in paediatric patients, because of the range of congenital and malignant conditions for which they may be hospitalised, and particular care is needed to ensure that documentation, handover, communication and bedside checking are effective and comprehensive. HTT and clinical users of blood This has been re-emphasised by the 2009 BCSH administration guidelines. By separating ‘clinical special requirements’ from those related to requirements automatic for certain ages, it may now be more practical to include clinical requirements on the prescription chart, helping to improve clinical communication. 2003 BCSH guidelines on transfusion of neonates and children should be implemented. RCPCH, RCN, staff in paediatric units and transfusion laboratories SHOT ‘Lessons for Paediatric Staff’ was produced 2006. SHOT in obstetrics was produced in 2007. NBS Paediatric conference was held in Feb 2007. 148 20. Paediatric Cases
21. Near Miss Reporting Definition A Near Miss event refers to any error that, if undetected, could result in the determination of a wrong blood group or transfusion of an incorrect component, but that was recognised before transfusion took place. Near Miss events have long been recognised as a good indicator of strengths and weaknesses within areas seemingly as disparate as the aircraft industry and blood transfusion, but where the common aim is to constantly strive to improve safety. Near Misses often have the same root cause as actual transfusion accidents, but their relatively higher frequency allows systems to be analysed in more detail and deficiencies corrected before accidents occur. The potential for an error to have a serious consequence depends on many factors, including the effectiveness of checks or barriers built into the process. Earlier SHOT annual reports have demonstrated that in many instances several errors may contribute to a ‘wrong blood’ event, and minor errors that evade the checks and barriers may play a significant part in a serious outcome for the patient. Previous SHOT data have shown that around 50% of all Near Miss events, where an incorrect component was recognised before transfusion took place, occur at the sampling stage. In last year’s annual report SHOT described phase 1 of a pilot study in which reporters were asked to submit data on sample errors detected during the ‘booking in’ process. This study showed that on average 3.8% samples received in transfusion laboratories are rejected because of a labelling error, though this ranged from 0.4% to more than 13% of samples received. This type of error is not reportable to SHOT as a Near Miss event, but needs to be monitored and trended at a local level. In phase 2 of the pilot study, reporters were asked to submit data on samples that appeared to be correctly labelled but that were found to be incorrect in some way during testing in the laboratory. These ‘Wrong Blood In Tube’ errors have the potential to result in issue of ABO-incompatible blood components to the patient, especially if there is no historical record available on laboratory computer systems, and are reportable as Near Miss events. It is pleasing to see that check procedures put in place as part of the laboratory Quality Management System have been successful in screening out some of these errors, and there have been some examples of good laboratory practice in identifying ‘out of the ordinary’ requests that uncovered serious errors. However, the percentage of sample errors attributed to medical staff (45%) seems disproportionately high, and it would be instructive to obtain denominator data as to what proportion of all samples are taken by which group of staff. This would be an intensive and difficult data-gathering exercise for reporters already fully committed to national and local audit activities, but even in the absence of the denominator data it should be noted that the figures obtained are comparable with previous SHOT annual reports. What is clear from the pilot study is the need for training and adherence to policies for venepuncture and sample labelling among all staff groups, including doctors. In 2009, there were 797 reports submitted under the heading of Near Miss, but as in previous years there has not been the resource within the SHOT team to analyse these effectively. The introduction of the new SHOT web-based reporting system in January 2010 allows the reporting of the whole range of Near Miss events, including WBIT errors, component selection and handling errors, and collection and preadministration errors, and this coupled with two new members of the SHOT team should make the analysis of these reports much more straightforward. 21. Near Miss Reporting 149
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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
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Case 1 Possible fatal reaction A ma
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adequate resources both for monitor
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Figure 12 Reaction by component typ
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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 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: always require notification by clin
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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