SHOT Annual Report 2009 - Serious Hazards of Transfusion

Recommendation
All pulmonary complications of transfusion should be recorded and reported to haemovigilance systems even if
they do not fully fit existing criteria. Research should be initiated to evaluate the current inclusion and exclusion
criteria, especially for TRALI and TACO. A register of possibly implicated donors should be kept by the blood
services.
Action: SHOT and its reporters, UK blood services and their R&D directorates
Patient identification
The patient identification check continues to be a critical point in the transfusion process where errors are made. These
occur due to staff not following established protocols, resulting in no true check of the patient taking place. These errors
are occurring despite the introduction of training and competency-assessments for all staff involved in the process, 4 and
in one example a classic error occurred and was not detected during a competency-assessment (Case 1, page 64). While
professional responsibility must be taken by all personnel involved at each stage in the process (SHOT recommendations
2007) it cannot be escaped that the final ‘bedside’ patient ID check is the last chance to detect certain errors that can
occur earlier in the chain, as well as being a critical point for new errors.
Control of Infection teams have run a very successful campaign in hospitals in which patients have been empowered,
and encouraged, to ask doctors and nurses whether they have washed their hands before they make physical contact
with the patient. A decrease in nosocomial infections has been documented. 15
SHOT recommends that a similar approach is now taken for patient ID – not just for blood transfusion, but across all
disciplines and specialities.
Recommendation
A patient education campaign should empower recipients of blood transfusion, and all patients undergoing tests,
procedures and surgery, or receiving drugs and therapies, to ask the staff, before they carry out the intervention:
‘Do you know who I am?’
Action: NBTC, DH, Trust/hospital CEOs
Clinical handover
A considerable number of cases, in various sections of the SHOT report, have occurred out of hours, at times when
staffing was reduced for various reasons, or when shift working meant that junior doctors were caring for large numbers
of patients with whom they were not familiar.
The European Working Time Directive (EWTD, 16 ) has been implemented by law across the UK but in a number of Trusts
there have been few practical arrangements put in place to deal with the inevitable problems for patient care that this
poses. Proactive new systems are required, and need to be implemented by high-level management within Trusts/
hospitals to ensure effective handover between shifts and teams, and continuity of patient care. This will not only
enhance patient safety and satisfaction but reduce unnecessary prolongation of stay due to communication failures.
The instigation of a method for formal handover of patients is essential if the EWTD and the associated shift working and
cross-covering are not to result in detriment to patient care. This would also provide an invaluable education session for
junior doctors, restoring a sense of being in touch with the clinical process. Despite the reduced hours, hospital doctors
6. Key Messages and Main Recommendations 23