SHOT Annual Report 2009 - Serious Hazards of Transfusion

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23. Glossary ACD AHTR AIHA ALI ALL AML ARDS ARF ATR BBT BBTS BCSH BMS BMT BP BSQR CAPA CCF CEO CDC CfH CLL CMO CMV COPD CPA CPAP CRF Cryo CS CTS CXR DAT DHTR DIC DNA DTR DU ECMO ED EDTA EI ET EWTD FBC FFP FY G&S GI GMC GP HAV Hb HBV HCV HDN HDU HEV HIV HL HLA HNA HPA HSC HTC HTLV HTT IAT IBCT IBGRL IBMS ICS ID Ig Acid citrate dextrose Acute haemolytic transfusion reaction Auto immune haemolytic anaemia Acute lung injury Acute lymphoblastic leukaemia Acute myelotic leukaemia Acute respiratory distress syndrome Acute renal failure Acute transfusion reaction Better Blood Transfusion British Blood Transfusion Society British Committee for Standards in Haematology Biomedical Scientist Bone marrow transplant Blood pressure Blood Safety and Quality Regulations Corrective and preventative actions Congestive cardiac failure Chief Executive Officer Complement dependent cytotoxicity Connecting for Health Chronic lymphocytic leukaemia Chief Medical Officer Cytomegalovirus Chronic obstructive pulmonary disease Clinical pathology accreditation Continuous positive airway pressure Chronic renal failure Cryoprecipitate Caesarean section Controlled temperature storage Chest X-ray Direct antiglobulin test Delayed haemolytic transfusion reaction Disseminated intravascular coagulation Deoxyribose nucleic acid Delayed transfusion reaction Duodenal ulcer Extracorporeal membrane oxygenation Emergency department Ethylenediaminetetraacetic acid Electronic issue Endotracheal European Working Time Directive Full blood count Fresh frozen plasma Foundation year Group and save Gastrointestinal General Medical Council General Practitioner Hepatitis A virus Haemoglobin Hepatitis B virus Hepatitis C virus Haemolytic disease of the newborn High dependency unit Hepatitis E virus Human immunodeficiency virus Hickman line Human leucocyte antigen Human neutrophil antigen Human platelet antigen or Health Protection Agency Health service circular Hospital Transfusion Committee Human T-cell leukaemia virus Hospital Transfusion Team Indirect antiglobulin test Incorrect blood component transfused International Blood Group Reference Laboratory Institute of Biomedical Science Intraoperative cell salvage Identification Immunoglobulin IHD IHN ISBT ITU IUT IV JVP LDF LDH LIMS MB-FFP MCT MDS MHRA MLA MOF NBS NBTC NHL NHSBT NIBTS NICU NISS NMC NOS NPSA NR NSAID OA PAD PAS PBSC PCS PMETB POCT PR PTP RA RAADP RBC RBRP RCA RR RTC SABRE SaBTO SAE SAR SCD SCID SCT SD SG SHA SNBTS SOB SOP SPN SpR SRNM TACO TAD TA-GvHD TKR TP TRALI TTI TTP UKTLC vCJD WBIT WBS WCC WEG Ischaemic heart disease International Haemovigilance Network International Society of Blood Transfusion Intensive Therapy Unit Intrauterine transfusion Intravenous Jugular venous pressure Leucocyte depletion filter Lactate dehydrogenase enzyme Laboratory information management system Methylene-blue fresh frozen plasma Mast cell tryptase Myelodysplastic syndrome Medicines and Healthcare products Regulatory Agency Medical laboratory assistant Multi-organ failure National Blood Service National Blood Transfusion Committee Non-Hodgkin’s lymphoma NHS Blood and Transplant Northern Ireland Blood Transfusion Service Neonatal Intensive Care Unit Normal ionic strength saline Nursing and Midwifery Council National occupational standards National Patient Safety Agency Normal range Non-steroidal anti-inflammatory drug Optimal additive Preoperative autologous deposit Platelet additive solution Peripheral blood stem cells Postoperative cell salvage Postgraduate Medical Education and Training Board Point of care testing Per rectum Post-transfusion purpura Rheumatoid arthritis Routine ante-natal anti-D prophylaxis Red blood cells Right blood right patient Root cause analysis Respiratory rate Regional transfusion committee Serious Adverse Blood Reactions and Events Advisory Committee on Safety of Blood Tissues and Organs Serious adverse event Serious adverse reaction Sickle cell disease Severe combined immunodeficiency Stem cell transplant Solvent detergent Steering Group Strategic Health Authority Scottish National Blood Transfusion Service Shortness of breath Standard operating procedure Safer practice notice Specialist Registrar Special requirements not met Transfusion-associated circulatory overload Transfusion-associated dyspnoea Transfusion-associated graft-versus-host disease Total knee replacement Transfusion practitioner Transfusion-related acute lung injury Transfusion-transmitted infection Thrombotic thrombocytopenic purpura UK Transfusion Laboratory Collaborative Variant Creutzfeld Jakob Disease Wrong blood in tube Welsh Blood Service White cell count Working Expert Group 152 23. Glossary
24. Acknowledgements The Steering Group would like to take this opportunity to thank the following individuals and organisations for their contributions without which the publication of this 13 th annual SHOT report would not have been possible: ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ The Blood Transfusion Services of the United Kingdom for funding and support The Royal College of Pathologists for their support and use of facilities The NHSBT Paediatric Transfusion Group Kirk Beard – NBS, for the provision of data relating to the issue of blood components from the Transfusion Services of the UK Neil Soni, Imperial College Medical School, Cliff Morgan, Royal Brompton Hospital, Edwin Massey, NHSBT Bristol, Nay Win, NHSBT Tooting – for expert review of the TRALI cases Clinical and Scientific staff, in hospitals and reference laboratories, who have contributed to the clinical and laboratory investigation of cases Ceri Frampton, WBS – for maintenance of the SHOT website MHRA and Assad Afzal of Charles McKenzie Consulting – for provision of the SABRE system and ongoing technical support Tahera Lakha, Personal Assistant to Clare Taylor Christine Smith, Personal Assistant to Hannah Cohen Victoria Peake and Kathryn Gradwell, SHOT Office staff David Gifford and Mark Williams for design and production of the report, and Frances Grant, copy editor. Art direction & illustration by Inscript Design www.inscriptdesign.com Design by Toast www.toastdesign.co.uk 24. Acknowledgements 153
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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
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Previous recommendations that are s
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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 and 152: always require notification by clin
Page 153 and 154: 21. Near Miss Reporting Definition
Page 155: 29 UK Resuscitation Council Emergen
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SHOT Annual Report 2009 - Serious Hazards of Transfusion

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