SHOT Annual Report 2009 - Serious Hazards of Transfusion

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Reporting categories The reporting categories for 2009 are unchanged since those published in the 2008 report. These are available to view and download from the SHOT website www.shotuk.org. Definitions Imputability The term ‘imputability’, as defined in the Blood Safety and Quality Regulations 2005, means ‘the likelihood that a serious adverse reaction in a recipient can be attributed to the blood component transfused’. 2 A scale of zero to three is used as shown below: 0 = excluded/unlikely – the evidence is clearly in favour of attributing the reaction to other causes. 1 = possible – the evidence is indeterminate for attributing the reaction to the blood or to alternative causes. 2 = likely/possible – the evidence is clearly in favour of attributing the adverse reaction to the blood or the blood component. 3 = certain – there is conclusive evidence beyond reasonable doubt attributing the adverse reaction to the blood or blood component. Imputability should not be confused with severity. A very mild reaction such as a pyrexia with no associated symptoms occurring during a platelet transfusion may have an imputability of 3. Conversely an apparently ‘severe’ reaction may be associated with comorbidities and may have little to do with the transfusion in progress at the time and therefore have an imputability of 0 or 1. In sick patients with complex conditions it is at times very hard to ascribe imputability. Transfusion-related mortality ■■ Death directly and solely caused by the transfusion reaction ■■ Death in which the transfusion reaction probably contributed and which may not have occurred at that time had the reaction not taken place ■■ Death which occurred at the time of or soon after a transfusion reaction, in which the reaction might have contributed to the death, and it is not possible to exclude this. These categorisations are made jointly by the reporter and the SHOT expert analyst. Inevitably such assessments may be a matter of informed opinion and there are times when it is an extremely hard judgement to make. To avoid confusion, the term imputability is not used in the SHOT report in relation to whether death was related to the transfusion reaction. Major morbidity The current categories of major morbidity used by SHOT are: ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ Intensive care admission and/or ventilation Dialysis and/or renal impairment Major haemorrhage from transfusion induced coagulopathy Jaundice including evidence of intravascular haemolysis Life-threatening acute reaction requiring immediate medical intervention* Potential risk of D sensitisation in a woman of childbearing age Persistent viral infection Acute symptomatic confirmed infection Reaction resulting in a low or high haemoglobin level of a degree sufficient to cause risk to life unless there is immediate medical intervention. * This category has been newly added by the SHOT Steering Group for 2009. 26 6. Key Messages and Main Recommendations
7. Incorrect Blood Component Transfused (IBCT) Definition The category Incorrect Blood Component Transfused (IBCT) comprises all reported episodes where a patient was transfused with a blood component that was intended for another patient or which was incorrect in terms of its specification. DATA SUMMARY Total number of cases 282 Implicated components Mortality/morbidity Gender Age Red cells 220 Deaths due to transfusion 0 FFP 17 Deaths in which reaction possibly contributed Platelets 26 Major morbidity 4 Other (specify) Unknown 19 Emergency vs. routine and core hours vs. out of core hours Where transfusion took place 3 Male Female Unknown 132 145 5 18 years+ 16 years+ to 18 years 1 year+ to 16 years 28 days+ to 1 year Birth to 28 days unknown Total 242 3 21 9 7 282 Emergency Routine Not known In core hours Out of core hours Not known/applicable 60 189 33 82 45 155 ED Theatre ITU/NNU/HDU/Recovery Wards Community Outpatient/day unit Not known 4 9 14 76 1 10 168 As in the 2008 report, this chapter comprises reports on 4 main types of errors which result in the transfusion of an incorrect blood component (plus 2 miscellaneous cases): ■■ ■■ ■■ ■■ Bedside blood administration errors Laboratory errors, testing and process errors Phlebotomy errors resulting in ‘wrong blood in tube’ (WBIT) Transfusion of components not meeting the patient’s special requirements (SRNM). The SRNM cases are divided according to whether they are clinical errors, largely of knowledge and/or communication (so that the transfusion laboratory did not know of the special requirement), and those which originated in the laboratory (in which the necessary information was available but not acted upon). In 2009 a total of 282 IBCT reports were received, which is a 7.6% increase compared with 2008, when 262 cases were included. The rate of reports of IBCT for 2009 was 9.7 per 100,000 components issued by the UK blood transfusion services compared with 9.2 in 2008. The data summary above shows that the data on cases in core hours and out of hours, and for the location of the patient when the error occurred, were poorly completed on the questionnaires. There were a total of 40 cases of IBCT occurring in patients under 18 years of age and these are discussed in more detail in the paediatrics chapter on page 140. The age range among adults was 18–97 years of age. 7. Incorrect Blood Component Transfused (IBCT) 27
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 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: 2005 Appropriate use of blood compo
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
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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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SHOT Annual Report 2009 - Serious Hazards of Transfusion

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