SHOT Annual Report 2009 - Serious Hazards of Transfusion

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Of the 69 clinical-based omissions to request irradiated blood, the indications for irradiation were as follows: ■■ 26 fludarabine or other purine analogue ■■ 16 Hodgkin’s disease ■■ 7 BMT or SCT ■■ 2 hairy cell leukaemia ■■ 2 AML ■■ 4 NHL ■■ 1 Waldenstrom’s macroglobulinaemia ■■ 3 lymphoma (unspecified) ■■ 1 myeloma ■■ 3 CLL ■■ 2 IUT ■■ 1 Campath therapy ■■ 1 unknown. Case 1 Non-irradiated red cells given to baby with previous IUT A baby who had been the recipient of intrauterine red cell transfusions (IUTs) was given 4 non-irradiated paedipaks of red cells on 2 separate occasions. The request form did state that the mother had antibodies and that there had been 3 IUTs, but the special requirements were not specified. The prescription form did not specify irradiated blood. Although a BMS might, on seeing the history of IUT, contact the clinicians for clarification, or decide to issue irradiated components, this is not core knowledge for laboratory staff. The requesting of special requirements for individual patients is a clinical responsibility. Case 2 Consultant assumes that need for irradiation is already documented from several years earlier An elderly patient had been on fludarabine for NHL since 2002 but no one had informed the laboratory that irradiated units would be indicated if any blood was required. The patient became anaemic and non-irradiated blood was issued and transfused. The consultant assumed that an alert was in the notes and on the pathology system and did not write the special requirement on the request form. Of the 5 clinical omissions to give a product both CMV negative and irradiated, the indications were as follows: ■■ 1 post stem-cell transplant for B cell lymphoma ■■ 1 myeloma ■■ 1 NHL ■■ 1 post treatment cerebellar medulloblastoma ■■ 1 anaemia post treatment for malignancy (paediatric). There were 5 cases in which CMV negative blood was indicated but not given. The indications were: ■■ 1 ECMO prior to heart-lung transplant ■■ 1 pregnancy (unrelated illness while pregnant) ■■ 1 pre-SCT ■■ 1 HIV with complications ■■ 1 unknown. Other clinical omissions to make a request for special requirements probably also related to lack of transfusion medicine knowledge in non-specialised staff admitting patients through the emergency department. In a number of these cases the need for special requirements was clearly documented as part of the patient medical history. In 15 of the 87 cases linked with the clinical omission to provide special requirements, the root cause of the problem related to the fact that the patient was undergoing shared care between 2 hospital sites, sometimes within the same 40 7. Incorrect Blood Component Transfused (IBCT)
Trust and sometimes in separate Trusts. Information not communicated included: ■■ irradiated products required due to treatment with purine analogues ■■ a diagnosis of Hodgkin’s disease ■■ requirement for HLA matched platelets ■■ previous SCT. Five of these 15 cases were documented as emergency admission via the ED. Case 3 Patient transferred to another ITU, special requirement details for SCT omitted A patient was transferred from his primary hospital, where he had undergone a stem-cell transplant, to another hospital within the same Trust in order to access an ITU bed. Each site has a blood transfusion laboratory. Platelets were requested by ITU and issued by the hospital transfusion laboratory. Irradiated components were not requested due to a lack of communication between the clinicians, and the laboratory records were separate from those at the originating hospital. Case 4 Special requirements for ECMO patient not communicated between hospitals A teenager requiring ECMO support prior to a heart-lung transplant was transferred from another Trust. The ECMO team did not notify the hospital transfusion laboratory of the requirement for CMV negative components. This request should also have been followed up by written confirmation on the form for special transfusion requirements. Special requirements may be second nature to the clinicians dealing with particular patient groups day to day, but may be very unfamiliar to more general staff, e.g. on ITU or in a surgical unit. Case 5 Error in transcription of patient details leads to special requirement not being met A patient was admitted via the ED and a sample sent for group and crossmatch. Although the details on the sample and request matched, the patient was incorrectly identified, the name was transposed and misspelt, and the date of birth was wrong. A new hospital number was therefore created, so historical details of special requirements were not accessed. The patient received a non-irradiated unit of blood. Case 6 Patient history not accessible due to change of address A patient admitted through the ED required multiple units of blood and received 2 units initially. The following morning a nurse looking after the patient informed the laboratory that the patient had previously received an SCT and required irradiated blood components. The patient had moved house and this was their first admission since relocating. The remaining units were returned to the laboratory and replaced with suitable irradiated red cells. There were a total of 4 cases in which clinicians did not inform the laboratory that an SCT had taken place in the past. Case 7 Vital information regarding a recent BMT not communicated to the transfusion laboratory A patient known to the Trust had FFP requested which was issued according to the historical blood group – O. However the patient had received a BMT (for CLL) at another hospital and the blood group had changed from group O to group B. None of the request forms indicated that the patient had had a recent BMT. Two new special requirement categories were identified by reporters including 1 latex allergy case and 2 cases of patients who required blood warmers due to cold agglutinin disease. In 56/87 cases the reporter stated that the BCSH guidelines relating to special requirements were not adhered to. 20 7. Incorrect Blood Component Transfused (IBCT) 41
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 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: All of the errors in this group wer
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
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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
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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
Page 121 and 122:
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
Page 129 and 130:
15. Transfusion-Associated Dyspnoea
Page 131 and 132:
16. Post-Transfusion Purpura (PTP)
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■■ 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
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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
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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
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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