SHOT Annual Report 2009 - Serious Hazards of Transfusion

More documents

Recommendations

Info

■■ ■■ ■■ ■■ ■■ ■■ ■■ Failure to follow protocol resulted in the issue of incompatible blood, resulting in a mild reaction: rigors and pyrexia. This error could have been prevented if the clinician had passed on to the laboratory the vital antibody information given by the patient. One case involved an interruption during crossmatching, which contributed to blood being electronically issued rather than issued following an immediate spin technique. Two cases involved NHSBT. In 1 case the BMS assumed NHSBT had completed all pre-transfusion testing, and issued the units, when they had not. In a second case NHSBT sent phenotyped units rather than crossmatched units and the BMS assumed they had been crossmatched and issued them. One case where an MLA failed to obtain full patient identification when taking a telephone request. One case in which a unit of FFP was incorrectly put into the laboratory database as group O D negative when it was group O D positive. It was then transfused to a group O D positive patient. Although the sequelae in this case was of no clinical significance the use of ‘copy’ facilities on LIMS when inputting critical component information must be disabled. One case in which a BMS edited the results to negative, twice; when warning messages of ‘wrong liquid level’, which invalidates the test, were clearly displayed on an automated analyser. One case where a DTR was caused by a missed anti-Jk b ; laboratory protocol did not follow BCSH guidelines on pre-transfusion testing. 22 (See Case 5, below.) Case 5 Different procedures might have prevented reaction A pre-transfusion sample from a patient with known anti-K gave weak reactions with the K negative screening cells by an automated technique. The screen was repeated on the second analyser, which gave negative results, and testing against a panel of red cells was not undertaken. Four days later the patient showed signs of a severe DHTR including deteriorating renal function, and anti-Jk b was detected in the post-transfusion sample. Retrospective testing on the pre-transfusion sample did not reveal anti-Jk b ; however, no different or additional techniques were used, and the sample was not referred for confirmation. The laboratory has since changed its policy, and a full antibody identification panel is undertaken on patients with known antibodies. Errors during crossmatching n = 3 ■■ 1 case where an incompatible unit was issued to a patient. ■■ 2 cases in which units were issued that expired before the day they were required. There were a number of cases of inappropriate electronic issue this year: 1 due to the patient’s historic record not being found, and 1 due to ‘interruption’ during crossmatch. There may have been others due to errors earlier in the pretransfusion testing process, e.g. sample age, but these have been reported under the appropriate sections and whether they then led to inappropriate EI is unclear. Case 6 Overriding warning signals A request was received for 6 units of blood for a patient with anti-D+C. Antigen negative blood was selected and an IAT crossmatch set up. On reading the crossmatch 1 unit was weakly incompatible (+) by IAT. This result was correctly entered into the LIMS but the unit was not physically quarantined from the compatible units. The units were then issued to the patient: a warning message was displayed for the incompatible unit but this was overridden and the emergency issue option used. The unit was transfused before the error was identified. COMMENTARY on pre-transfusion testing Numbers of procedural errors remain constant with 40 in 2008 and 38 this year. Although not as marked as in the ‘wrong blood incident’ section, it appears that there are a disproportionately high number of errors occurring out of hours, even after taking workload into consideration. Local investigation into these errors must be carried out and a full RCA performed to ascertain why they occurred. SHOT endorses the recommendations of the UK Transfusion Laboratory Collaborative with regard to staffing levels, technology, training and competencies both in and outside core working hours. 10,11 50 7. Incorrect Blood Component Transfused (IBCT)
IT must be used to its full potential. It is difficult to understand why the following are not set up on LIMS: ■■ Preventing the issue of units that expire before the ‘time required’. ■■ Reflex requesting of an antibody identification based on a positive result in the antibody screen so that there is clear, outstanding work still to perform before a crossmatch. These points are also highlighted in the IT chapter. Learning point ■■ Use of automation and IT can increase the security of testing but only if the messages/flags given are heeded and acted on appropriately. It is disappointing to report a number of examples this year that involve qualified staff overriding information, leading to the transfusion of what could be unsuitable units of blood. It is important that staff understand all warning messages and the necessary, appropriate actions to take following warnings. The following learning points from previous reports remain pertinent: ■■ Errors are still being made in using inappropriate samples. Computer warning flags are a useful tool but must be backed up with strong theoretical knowledge. New BCSH Guidelines on compatibility procedures in blood transfusion laboratories are in progress. These guidelines will simplify sample age requirements. ■■ ■■ ■■ Competency-assessment must comprehensively cover the areas of phenotype selection, antibody history and appropriate use of EI. Competency-assessment must comprehensively cover all warning messages from analysers and the LIMS and staff must be able to demonstrate appropriate actions. Transfusion laboratories must have thorough search strategies when looking for patient histories in order to find and reconcile multiple entries for a patient. 23 Laboratory-based cases of SRNM n = 67 The 67 SRNM errors have been divided into SRNM based on the following: ■■ poor serological knowledge/failure to recognise the special needs of a specific patient group ■■ failure to consult patient records thoroughly. This section mirrors that of previous years in which the majority of errors were associated with either failing to notice/ heed warning flags or absence of warning flags, either because they have not been added or because they have been incorrectly deleted. SRNM due to poor serological knowledge/failure to recognise the need for special requirements n = 27 Failure due to poor serological knowledge/carelessness in selection n = 11 ■■ An incorrect order for blood was made for a neonate. Anti-D+Fy a +Jk b antibodies were identified in the mother, who initially refused to have a sample taken, so blood was crossmatched against the baby’s sample in which only anti-D was detectable. The first BMS failed to order Jk b negative units and the second BMS did not pick up on the error when crossmatching the blood. 7. Incorrect Blood Component Transfused (IBCT) 51
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 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: Three interpretation errors occurre
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
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
Page 119 and 120:
RECOMMENDATIONS New recommendations
Page 121 and 122:
Table 42 Cases classified according
Page 123 and 124:
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
show all

SHOT Annual Report 2009 - Serious Hazards of Transfusion

Create successful ePaper yourself

Delete template?

Save as template?