SHOT Annual Report 2009 - Serious Hazards of Transfusion

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IBCT RECOMMENDATIONS FROM PREVIOUS YEARS (all sections) Year first made Recommendation Target Progress 2008 Competency-assessment of staff involved in the transfusion process must be relevant to the person’s core role and knowledge requirements. This must be carried out in accordance with NPSA SPN 14. Clinical risk managers, HTTs MHRA annual compliance reports ask whether competency-assessment is carried out. MHRA and CPA (UK) Ltd inspectors will look for evidence of competency-assessment. 2008 All staff must be trained (and competency-assessed) in recognising the different blood components and their labels. Clinical risk managers, HTTs NPSA has issued new guidance and deadlines for completion. 2008 Laboratory procedures should be validated in line with the BSQR and should be revisited following an error as part of Corrective and Preventative Actions. Transfusion laboratory managers 2008 Competency-assessment in laboratories must be linked to process. BMS staff must be competent in performing the test but must also have a thorough understanding of the context in which the test is being performed, i.e. the test in relation to a specific patient and the clinical information. Basing competencyassessment on National Occupational Standards (NOSs) will enable this, as NOSs have both ‘Performance’ criteria and ‘Knowledge and Understanding’ criteria. Transfusion laboratory managers 2008 The UK Transfusion Laboratory Collaborative has recommended minimum standards for hospital transfusion laboratories in terms of staffing, technology, training and competence. This document has been widely disseminated and should form the basis for future laboratory planning. CEOs, Pathology managers Report published in Transfusion Medicine and The Biomedical Scientist, September 2009. 10,11 Report circulated to all CEOs in England, Wales and Northern Ireland. SCTAC considering. 2008 Shared care discharge notification, giving tick-box options for special requirements, with reasons, should be completed by the referring clinicians and forwarded to the receiving hospital through the laboratory network. NBTC, RTCs 2007 Education of doctors and nurses involved in transfusion must continue beyond basic competency to a level where the rationale behind protocols and practices is understood. Transfusion medicine needs to be a core part of the curriculum. NBTC, Royal Colleges, GMC Royal Colleges and Specialist Societies Committee working with NBTC. 2007 Staff involved in blood component transfusion must be aware of their professional accountability and responsibility. GMC, NMC, IBMS, professional insurance schemes 56 7. Incorrect Blood Component Transfused (IBCT)
7.1 Errors Relating to IT Systems (IBCT IT) In 2009, there were 61 reported incidents of IBCT errors relating to IT systems, compared with 44 in 2008 and 25 in 2007 (see Table 23). Forty-six incidents originated in the transfusion laboratory. Forty-seven cases involved red cells, 10 platelets and 2 plasma components. Six of the 61 cases occurred in children (1–8 years) and 3 in infants. Table 23 IT Systems Errors NB some reports involved more than 1 category of error Error Reports Non-irradiated component transfused Antigen positive unit transfused Non-CMV neg unit transfused Wrong group after SCT Electronic issue error Other Failure to consult historical record Historical record not identified Ignored/missed warning flag 4 1 3 1 1 20 6 3 9 1 (red cells crossmatched on outdated sample) 1 (failure to issue platelets in PAS) Failure to update warning flags Computer system ‘down’ 5 1 1 2 1 1 (failure to update product code led to issue of adult FFP for child) 1 (manual component selection error – cryo instead of FFP) Data not transferred from old system Electronic blood tracking system errors/misuse Failure to merge or reconcile records 3 3 9 1 5 4 1 2 7 (out of expiry date/ time components issued – see text) 1 IBCT 1 (unable to issue red cell unit c/o discrepant ID numbers) Error/deficiency in computer system or misuse 13 1 4 1 3 8 (miscellaneous – see text) TOTAL 61 9 19 3 11 5 21 7.1 Errors Relating to IT Systems (IBCT IT) 57
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Annual Report 2009 Affiliated to th
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Requests for further information sh
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1. Foreword The Serious Hazards of
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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 and 58: Case 8 When the laboratory knows of
Page 59: ■■ All staff must take full pro
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
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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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