SHOT Annual Report 2009 - Serious Hazards of Transfusion

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Serious Hazards of Transfusion (SHOT) Steering Group Chair Medical Director Operations Manager Research Analyst Transfusion Liaison Practitioner Clinical Incidents Specialist Laboratory Incidents Specialist National Coordinator (HPA Centre for Infections) Dr Hannah Cohen Dr Clare Taylor Mr David Mold Mrs Hilary Jones Mr Tony Davies Mrs Julie Ball Mrs Hema Mistry Ms Lisa Brant Working Expert Group (WEG) & Writing Group, on behalf of the SHOT Steering Group Chair: Dr Clare Taylor Dr Hannah Cohen, Mr David Mold, Mrs Hilary Jones, Mr Tony Davies, Mrs Hema Mistry, Mrs Julie Ball Mrs Debbie Asher, Ms Caoimhe Cawley, Mr Bill Chaffe, Dr Catherine Chapman, Mrs Alexandra Gray, Ms Joan Jones Ms Clare Milkins, Dr Helen New, Dr Derek Norfolk, Dr Fiona Regan, Mrs Elizabeth Still, Dr Hazel Tinegate Steering Group (SG) Chair: Dr Hannah Cohen Name Prof John Barbara Prof Mark Bellamy Dr Su Brailsford Ms Lisa Brant Ms Caoimhe Cawley Mr Bill Chaffe Prof David Cox Dr Roger Eglin Dr P Adrian Evans Mr John Getty Dr Brenda Gibson Dr Patricia Hewitt Ms Joanne Hoyle Ms Mervi Jokinen Ms Joan Jones Prof John S P Lumley Sheila MacLennan Mr John Marriott Dr Brian McClelland Dr Kieran Morris Dr Andrew Mortimer Dr Tim Nokes Dr Derek Norfolk Dr Jonathan Potter Dr Daghni Rajasingam Ms Joan Russell Dr Dorothy Stainsby Dr Clare Taylor Dr Andrew Thillainayagam Dr Dafydd Thomas Dr Lorna Williamson Representing Founder Member The Intensive Care Society Health Protection Agency and NHS Blood and Transplant SHOT National Coordinator for Infectious Hazards Health Protection Agency and NHS Blood and Transplant Institute of Biomedical Science NHS Confederation Transfusion Microbiology Specialist, NHSBT College of Emergency Medicine Royal College of Surgeons Royal College of Paediatrics and Child Health Consultant Specialist in Transfusion Microbiology, NHSBT Royal College of Nursing Royal College of Midwives Institute of Biomedical Science Founder Member UK Forum Lay Member Founder Member Royal College of Pathologists Royal College of Anaesthetists British Society for Haematology British Committee for Standards in Haematology, National Blood Transfusion Committee Royal College of Physicians Royal College of Obstetricians and Gynaecologists National Patient Safety Agency (co-opted) Past National Medical Coordinator Medical Director of SHOT British Society of Gastroenterology British Blood Transfusion Society Founder Member NB All members of the WEG are members of the Steering Group in their own right
Requests for further information should be addressed to: Non-infectious hazards Infectious hazards SHOT Office Manchester Blood Centre Plymouth Grove Manchester M13 9LL Ms Lisa Brant Clinical Scientist HPA Centre for Infections 61 Colindale Avenue London NW9 5EQ Tel +44 (0) 161 423 4208 Tel +44 (0) 20 8327 7496 Fax +44 (0) 161 423 4395 Fax +44 (0) 20 8200 7868 Website www.shotuk.org Email lisa.brant@hpa.org.uk Enquiries Email shot@nhsbt.nhs.uk clare.taylor@nhsbt.nhs.uk hannah.cohen@uclh.nhs.uk david.mold@nhsbt.nhs.uk hilary.jones@nhsbt.nhs.uk julie.ball@nhsbt.nhs.uk hema.mistry@nhsbt.nhs.uk tony.davies@nhsbt.nhs.uk Copyright notice Please cite this work as: Taylor C (Ed.), Cohen H, Mold D, Jones H, et al, on behalf of the Serious Hazards of Transfusion (SHOT) Steering Group. The 2009 Annual SHOT Report (2010). This work was undertaken by SHOT. The work was funded by NHS Blood and Transplant, Northern Ireland Blood Transfusion Service, Scottish National Blood Transfusion Service and the Welsh Blood Service through the UK Forum. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of SHOT, or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK (www.cla.co.uk). Enquiries concerning reproduction outside the terms stated here should be sent to SHOT at the address printed on this page. Making duplicate copies of this Report, or use of the data within, for legitimate clinical, scientific, educational or other non-commercial purposes is permitted provided that SHOT is identified as the originator of the information. Making alterations to any of the information contained within, or using the information in any other work or publication without prior permission, will be a direct breach of copyright. The use of registered names, trademarks etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulation and therefore free for general use. Copyright © Serious Hazards of Transfusion (SHOT) 2010 Published July 2010 ISBN 978-0-9558648-2-7 Printed on recycled paper
Page 1: Annual Report 2009 Affiliated to th
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 and 18: Update on 2008 recommendations Last
Page 19 and 20: Numbers of components issued In 200
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
Page 71 and 72:
Core hours vs. out of hours and Whe
Page 73 and 74:
Broad breakdown of where primary er
Page 75 and 76:
Case 6 Dilute (possible drip arm) s
Page 77 and 78:
Case 10 Over-transfusion following
Page 79 and 80:
9. Handling and Storage Errors (HSE
Page 81 and 82:
Excessive time to complete administ
Page 83 and 84:
etween removing the component from
Page 85 and 86:
10. Adverse Events Relating to Anti
Page 87 and 88:
Omission or late administration of
Page 89 and 90:
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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adequate resources both for monitor
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
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RECOMMENDATIONS New recommendations
Page 121 and 122:
Table 42 Cases classified according
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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
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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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