SHOT Annual Report 2009 - Serious Hazards of Transfusion

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Table 11 Numbers of true IBCT cases and rate per 100,000 blood components issued 2003–2010 NB These figures exclude HSE and I&U; they are not categorised as IBCT and are reported in separate chapters. Year Number of cases reported on IBCT questionnaires Reports per 100,000 components 2003 252 7.4 2004 262 7.8 2005 252 8.1 2006 198 6.6 2007 164 5.6 2008 262 9.2 2009 282 9.7 Figure 7 IBCT cases 1996–2009 showing ABO-incompatible transfusion NB HSE and I&U cases are no longer included in the IBCT total (see 2008 Report) and are removed from the IBCT totals in this chart from 2003 onwards. 350 300 Key All other IBCT cases ABO incompatible red cell transfusions 250 Number of reports 200 150 281 226 243 242 252 268 100 154 156 190 71 105 152 50 50 0 13 1996–97 36 1997–98 26 1998–99 34 1999–00 17 2000–01 22 2001–02 (15 months) 26 2003 19 2004 10 2005 8 2006 12 10 14 2007 2008 2009 Year of report The histogram above shows the total number of reports in the IBCT category each year since SHOT reporting commenced in 1996. Until 2008, cases of inappropriate and unnecessary transfusion and handling and storage errors were included in this total. For the first time last year these were removed from IBCT and reported in separate chapters, as they do not involve transfusion of an incorrect component. This results in an apparent drop in IBCT cases. In reality the number of reports in all categories has continued to rise, as participation in haemovigilance has increased and reporters are becoming familiar with the reporting mechanisms and the benefits of contributing cases. 28 7. Incorrect Blood Component Transfused (IBCT)
Table 12 Summary of IBCT cases Type of event No. of cases 2008 No. of cases 2009 Administration of wrong blood component ■■ ABO-incompatible red cells ■■ D-incompatible red cells ■■ Compatible wrong blood components ■■ Incorrect component type ■■ Other 4 3 32 3 5 47 10 1 21 1 7 40 Wrong blood in tube ■■ ABO-incompatible red cells ■■ D-incompatible red cells ■■ Incorrect Hb ■■ Compatible 4 0 1 0 5 2 1 0 1 4 Special requirements not met – Clinical ■■ Irradiation and CMV ■■ Other special requirements (including those arising from SCT) 70 6 76 79 8 87 Special requirements not met – Laboratory ■■ Irradiation and CMV ■■ Other special requirements ■■ Blood Service errors and omissions 30 11 0 41 36 31 0 67 Laboratory errors (excluding SRNM) ■■ Wrong blood issued ■■ Wrong ABO/D type for SCT patient ■■ Pre Tx errors – testing ■■ Pre Tx errors – procedural 39 4 8 40 91 21 13 9 39 82 Miscellaneous IBCT 2 2 TOTAL 262 282 Summary of key data for all IBCT cases n = 282 Mortality entirely related to IBCT event n = 0 There were no cases this year in which a patient died directly and solely as a result of an incorrect blood component transfused. Mortality in which IBCT event contributed n = 3 There were 3 cases this year in which a patient died following a reaction to ABO-incompatible blood, where this may have contributed to the death. Two arose from administration errors (see Case 1 and Case 2, below) and 1 resulted from a phlebotomy error in the ED (Case 1, page 38). In these cases it is very difficult to define a causal link, but equally it is impossible to categorically state that an incompatible transfusion did not have an additional impact in an already critically ill patient. Major morbidity n = 4 There were 2 cases of major morbidity resulting from administration errors, 1 from a phlebotomy error at the bedside involving misuse of an electronic aid to patient identification and 1 relating to a laboratory error. These are discussed in the relevant sections. 7. Incorrect Blood Component Transfused (IBCT) 29
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 and 30: 2005 Appropriate use of blood compo
Page 31: 7. Incorrect Blood Component Transf
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
Page 91 and 92:
RECOMMENDATIONS New recommendations
Page 93 and 94:
Case 1 Possible fatal reaction A ma
Page 95 and 96:
adequate resources both for monitor
Page 97 and 98:
Figure 12 Reaction by component typ
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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
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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
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 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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