SHOT Annual Report 2009 - Serious Hazards of Transfusion

Case 8
When the laboratory knows of a special requirement it should not have to be reiterated on request
A request was made for platelets. The BMS noted the requirement for HLA matched platelets and ordered them to
arrive to cover overnight and for use the next day. The on-call BMS booked in and issued the HLA matched platelets.
The platelets were not used overnight and the pack was returned to stock the following morning. A different BMS
on specimen reception received a request for a unit of platelets for the patient. The need for HLA matched platelets
was not mentioned. The BMS failed to notice the comment regarding the need for HLA matched platelets, entered on
the laboratory system and on the laboratory whiteboard, and a pool of non-HLA matched platelets was issued and
transfused. On discovering the error the ward was contacted and reminded that the patient needed HLA matched
platelets and that this needed to be stated on the request. The HLA matched platelet was then reissued to the patient
and transfused.
Case 9
Checking the need for a special requirement is the responsibility of all staff groups
A patient had received fludarabine and required irradiated components. While being transfused irradiated components,
the patient stated that the blood he had received on a previous occasion had not been irradiated. An investigation
ensued.
In the clinical area:
• the patient’s notes did not have an ‘irradiated blood’ alert sticker on them
• the prescription did not state irradiated blood – the relevant field on the prescription was blank.
In the laboratory:
• the patient’s notes on LIMS contained a large amount of information including that irradiated blood components
were required.
Clearly a number of problems led to this error: omissions at ward level and an error on the part of the BMS. Was this
simply a lapse by the BMS or could the notes on the LIMS have been clearer?
COMMENTARY on SRNM laboratory cases
This year has seen an increase in the number of paediatric cases: 7 cases where MB-treated FFP should have been
issued to patients under 16 years of age and 3 cases where apheresis platelets should have been issued to the same
patient group. 24 Two cases resulted from patients having more than 1 record in which data was not successfully merged
or reconciled and as a result warning flags were deleted/missed during the transfer process.
Failure to provide irradiated components when required was the biggest group (22/67 cases). Some hospitals are
relying on a ticked box on a request form to highlight the need for irradiation. This can be missed in the laboratory.
As recommended in 2008, a more robust mechanism should be in place for informing the laboratory that irradiated
components are required. The laboratory must then ensure that these requirements are consistently met without the
need for further prompts.
Once again the failure of laboratory staff to select appropriate components when warnings flags are present is hard to
understand, especially as the majority of the cases reported were during normal working hours. There does seem to
be a particular problem when there are multiple special requirements. IT should be used to its full potential to prompt
staff about special requirements either through algorithms based on date of birth and/or gender, or via warning flags.
Warnings need to be clear and unambiguous and must be linked to the patient record, not one sample. Staff must then
be competency-assessed to ensure that they fully understand all prompts/warnings/flags.
Case 8 above shows, again, that multiple errors, both clinical and laboratory, often contribute to cases of
mistransfusion.
7. Incorrect Blood Component Transfused (IBCT) 53