SHOT Annual Report 2009 - Serious Hazards of Transfusion

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Learning points ■■ ■■ ■■ Simple yet robust procedures must be in place for recording special requirements. Use of a ‘shared care’ document is helpful but the information from this document must be clearly recorded in the LIMS. Once informed of the need for a special requirement the laboratory must ensure that the requirement is consistently met without the need for further prompts. Mistransfusion is often a result of multiple errors. It is important to investigate these incidents thoroughly by performing a full RCA so that all appropriate CAPA can be instigated. The following learning points from previous reports remain pertinent: ■■ Assessment of staff working in the transfusion department must cover competency in the provision of blood components for specific groups of patients, and understanding the importance and use of ‘special requirements’ flags. ■■ Laboratories must give thought to the nomenclature used to describe phenotype requirements. It may be prudent to simply state the antigens that the red cells should lack, rather than use Weiner terminology, for example, which requires interpretation. Errors involving NHSBT These are discussed in the text but grouped here for clarity. There were 2 cases where the primary error was made by NHSBT and then not noticed by the hospital laboratory: ■■ platelets of the wrong ABO group were sent ■■ blood that was older than requested was sent. There were 2 further errors where it is unclear whether there were mistakes or simply miscommunication between the hospital laboratories and 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. The BMS assumed they had been crossmatched and issued them. RECOMMENDATIONS RECOMMENDATIONS for clinical IBCT cases ■■ A transfusion checklist should be developed, ideally with an accompanying transfusion record section, in a similar style to the WHO surgical checklist (http://whqlibdoc.who.int/publications/2009/9789241598590_ eng_checklist.pdf). This approach is a proven aid to patient safety and could prevent omission of critical steps in the process. Action: NBTC and counterparts in Scotland, Wales and Northern Ireland ■■ All point of care testing devices for Hb estimation must be fully validated and internal quality control and participation in external quality assurance schemes must be ensured. (See also recommendation on page 74.) Currently this is not the case for calculated Hb estimates from blood gas analysers. A study to evaluate the utility of these devices for Hb measurement should be undertaken and guidance and recommendations issued. Action: NBTCs, NEQAS, SHOT 54 7. Incorrect Blood Component Transfused (IBCT)
■■ All staff must take full professional responsibility for their part in the transfusion process. Personnel involved at the point of component administration must understand that this is the final opportunity to check for errors earlier in the chain, and the sole remaining opportunity to be certain of the recipient’s identity. Action: CEOs of Trusts/hospitals, HTCs and HTTs ■■ The existence, and the importance, of special transfusion requirements must be taught to junior doctors in all hospital specialities. Local mechanisms for ordering and prescribing components need to facilitate correct ordering, and remind clinical and laboratory personnel where possible. Action: CEOs of Trusts/hospitals, HTCs ■■ Hospitals must ensure that they have protocols and documentation systems for: transportation of blood components accompanying patients transferring to other sites administration to patients who may be permitted to receive blood components at home ongoing information transfer between hospitals when patients have shared care at 2 or more sites. Action: HTCs, HTTs RECOMMENDATIONS for laboratory IBCT cases ■■ Many hopes of error reduction have been pinned on extending automation and IT. An emerging theme from this year’s report is that frequently it is still up to well trained staff, with underpinning knowledge, to interpret and heed warnings and flags and, unless appropriate actions are taken, errors will continue to occur. Action: Lead BMS for hospital transfusion laboratories, transfusion laboratory managers ■■ There is a requirement for manufacturers to provide affordable, secure automation for smaller laboratories that bridges the gap between manual methods and large ‘walk away’ analysers. Action: Manufacturers of blood grouping equipment, IT working group of the NBTC ■■ The number of errors in the SRNM category has remained high for a number of years. Laboratories must make a concerted effort to tackle this problem. This should be done at a local level as there will be different root causes in different Trusts. Action: HTTs ■■ Blood services should review the packaging of components that look similar, to assess whether they could be more easily identified, particularly when those components are often used in emergency situations. Action: UK Blood services ■■ The IT system should be configured to flag a component discrepancy between that ordered and that issued, and this should be fully validated. If this is not possible locally then these development requirements must be raised with LIMS suppliers. Action: HTTs, manufacturers of blood grouping equipment, IT working group of the NBTC 7. Incorrect Blood Component Transfused (IBCT) 55
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Annual Report 2009 Affiliated to th
Page 3 and 4:
Requests for further information sh
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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 and 54: Three interpretation errors occurre
Page 55 and 56: IT must be used to its full potenti
Page 57: Case 8 When the laboratory knows of
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
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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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