SHOT Annual Report 2009 - Serious Hazards of Transfusion

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5. Summary of Main Findings and Cumulative Results Data analysed for this report were collected between 1 st January 2009 and 31 st December 2009. Numbers of questionnaires completed The total number of questionnaires reviewed this year is 1279. This represents an increase of 23% since 2008, when 1040 were reviewed. The figures are summarised in Table 7 and Figure 4 below. Table 7 Summary of reports reviewed 2009 IBCT I&U HSE ANTI-D ATR HTR TRALI TACO TAD PTP GvHD TTI TA- AUTO- LOGOUS Total 282 92 196 186 400 47 21 34 4 0 0 3 14 1279 Figure 4 Cases reviewed n = 1279 I&U 92 (7.2%) HSE 196 (15.3%) IBCT 282 (22%) Autologous 14 (1.1%) Anti-D 186 (14.5%) TTI 3 (0.2%) TAD 4 (0.3%) TACO 34 (2.7%) TRALI 21 (1.6%) HTR 47 (3.7%) ATR 400 (31.3%) Clinical versus laboratory errors Of the total 1279 errors, 230 originated primarily in the hospital transfusion laboratory (149 IBCT, 38 anti-D and 43 handling and storage errors) which is 18% of the total reports, the same proportion as in 2008. Laboratory errors also accounted for 149 of 282 cases of IBCT, i.e. 53% of IBCT reports, compared with 50% in 2008. 14 5. Summary of Main Findings and Cumulative Results
Numbers of components issued In 2009 the number of components issued by the Blood Transfusion Services of the UK increased for the first time in over 10 years, by 2%. The increase has been similar across all 4 types of labile component (see Table 8, below). Table 8 Yearly summary of issues by the 4 UK Blood Services 1999–2009 Year Red Blood Cells Platelets FFP Cryoprecipitate Totals 1999–2000 2,737,572 249,622 365,547 94,114 3,446,855 2000–2001 2,706,307 250,259 374,760 95,456 3,426,782 2001–2002 2,679,925 251,451 385,236 88,253 3,404,865 2002–2003 2,678,098 251,741 377,381 92,768 3,399,988 2003–2004 2,607,410 264,539 372,855 95,417 3,340,221 2004–2005 2,428,934 258,528 313,019 102,719 3,103,200 2005–2006 2,316,152 259,654 320,852 106,139 3,002,797 2006–2007 2,235,638 255,474 306,444 116,672 2,914,228 2007–2008 2,174,256 258,419 295,085 117,699 2,845,459 2008–2009 2,209,153 266,312 306,740 121,555 2,903,760 Table 9 Total issues of blood components from the Transfusion Services of the UK in the financial year 2008–2009 Transfusion Service Red Blood Cells Platelets FFP Cryoprecipitate Totals National Blood Service 1,849,370 226,644 260,265 104,954 2,441,233 Welsh Blood Service 94,806 8,834 12,777 2,475 118,892 Scottish National Blood Transfusion Service Northern Ireland Blood Transfusion Service 211,813 23,969 27,077 13,370 276,229 53,164 6,865 6,621 756 67,406 TOTAL 2,209,153 266,312 306,740 121,555 2,903,760 In addition to the components issued by the four UK Blood Transfusion Services, there is significant usage of Octaplas ® , the solvent detergent treated FFP (SD-FFP), which is a batched pharmaceutical product available from Octapharma. In the financial year 2008–2009 there were 52,963 units of Octaplas ® sold to hospitals and Trusts in the UK. This brings the total number of units issued to 2,956,723. 5. Summary of Main Findings and Cumulative Results 15
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: Update on 2008 recommendations Last
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
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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
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Antibody only detectable in eluate
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Table 39 Serology, laboratory signs
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Table 40 DHTRs - New specificities
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13. Transfusion-Related Acute Lung
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Classification of cases according t
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Comparative data on implicated comp
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Case Histories TRALI probable Case
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RECOMMENDATIONS New recommendations
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Table 42 Cases classified according
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Clinical details and transfused flu
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Cases in which RBC transfusion was
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exchange in patients with TTP. 43 I
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15. Transfusion-Associated Dyspnoea
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16. Post-Transfusion Purpura (PTP)
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■■ The requirement to irradiate
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Two incidents (both bacterial, desc
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Viral and parasitic TTIs Since 1996
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The most likely source of the organ
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19. Autologous Transfusion Definiti
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RECOMMENDATIONS There are no new re
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Introduction and overall trends In
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incident group O D negative units w
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Table 47 Types of reactions for eac
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always require notification by clin
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21. Near Miss Reporting Definition
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29 UK Resuscitation Council Emergen
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24. Acknowledgements The Steering G
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