SHOT Annual Report 2009 - Serious Hazards of Transfusion

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8. Inappropriate and Unnecessary Transfusion (I&U) Definition ■■ ■■ ■■ Inappropriate and unnecessary transfusions are those given on the basis of erroneous, spurious or incorrectly documented laboratory results for haemoglobin, platelets and coagulation tests. Transfusions given as a result of poor understanding and knowledge of transfusion medicine, such that the decision to transfuse puts the patient at significant risk or is actually harmful. Under-transfusion or delayed transfusion resulting in poorer patient outcome. DATA SUMMARY Total number of cases 92 Implicated components Mortality/morbidity Red cells 68 Deaths due to transfusion 0 FFP 7 Platelets 11 Deaths in which reaction was implicated Deaths in which reaction possibly contributed Cryoprecipitate 4 Major morbidity 2 1 1 Red cells and platelets 2 Gender Age Emergency vs. routine and core hours vs. out of core hours Where transfusion took place Male Female Unknown 35 55 2 18 years+ 16 years+ to 18 years 1 year+ to 16 years 28 days+ to 1 year Birth to 28 days Total 77 2 7 2 4 92 Emergency Routine Not known In core hours Out of core hours Not known/applicable 28 54 10 13 8 71 ED Theatre ITU/NNU/HDU/Recovery Wards Outpatient/day unit Not known 1 1 6 9 1 74 There were 92 reports of inappropriate and unnecessary transfusion concerning 94 patients. One report concerned an identical prescription error affecting 3 neonates. Emergency vs. routine In 28 cases the event took place in an emergency setting and in 54 cases in a routine or elective setting; in 10 cases this information was not available. Age of the patients There were 77 patients over 18 years old and 15 paediatric cases (one involving 3 neonates, see above): 2 between 16 and 18 years of age, 7 between 1 and 16 years, 2 between 28 days and 1 year, and 4 between birth and 28 days. Gender There were 35 male and 55 female patients. In 2 cases the gender of the patient was not documented. 66 8. Inappropriate and Unnecessary Transfusion (I&U)
Core hours vs. out of hours and Where the transfusion took place These two sections were very poorly answered again this year: 76% did not specify the time of transfusion and 85% did not specify where the transfusion took place. The new Dendrite web-based SHOT reporting system should rectify this problem. Mortality There were 2 deaths in this group where the transfusion of red cells possibly or probably contributed to the death. As the patients died very soon after receiving the red cells, full investigations were not performed. Case 1 Unnecessary transfusion based on Hb result for a different patient A patient with disseminated carcinoma was admitted and a sample for FBC was taken by a member of nursing staff. The hospital policy for positive ID of the patient was not followed and the sample tube was labelled with a different patient’s details. (The report does not state whether a transfusion sample was mislabelled at the same time, only that both patients were group O D positive.) The patient’s true Hb was 10.9 g/dL and there was no indication of bleeding or haemolysis. The incorrect patient’s Hb was 6.0 g/dL and based on this a 3-unit transfusion was prescribed without querying the surprisingly low result. The patient suffered acute pulmonary complications during the first unit with a drop in pO 2 , and the transfusion was stopped. A CXR post transfusion may have indicated TACO or TRALI. The patient deteriorated rapidly and died. The report stated that the death was considered to be possibly related to transfusion. This patient did not require transfusion. Although he was suffering from carcinoma, the exact cause of death of the patient when it occurred is unclear. It seems likely that the administration of the red cells played a part by contributing to respiratory compromise. Case 2 Request from BMS for repeat sample not heeded Following abdominal surgery a patient fell in the ward and fractured her femur. Her most recent previous Hb was 15.9 g/dL. On testing a new FBC sample the BMS called the ward, gave an Hb of 6.1 g/dL, and requested another sample as he thought the result was incorrect. However, the result was passed to the medical team on the ward round by a nurse who did not mention the need to repeat the test. On the basis of the erroneous result, even though clinically there was not extensive bleeding, a 4-unit red cell transfusion was ordered by the consultant, and all 4 units were given without further review. The patient’s Hb was 20.2 g/dL before surgery on the following day, and the anaesthetist was aware of this. The patient developed cardiac failure and died. This was thought to be probably related to the excessive transfusion. This case reveals a number of omissions and errors of judgement. The crucial message to repeat the test was not passed on, but at the same time the doctors on the ward round did not, from a clinical perspective, assess the results to be inaccurate. No clinical assessment seems to have been made, nor basic observations. In any patient it is very rarely appropriate to transfuse 4 units of red cells back to back without review and repeat sampling – perhaps only in cases of massive active haemorrhage. It is possible the outcome might have been different had venesection been carried out once the very high Hb was discovered. There are 5 cases this year in which requests for repeat samples, made by the haematology laboratory BMS, were ignored. In addition there is a case in which non-validated haematology results were viewed on the computer system and acted upon, while the lab was in the process of checking it for a clot. There seems little point in informing a clinical team of an erroneous result, verbally or electronically, when there is a risk of communication failure. The laboratory should call to request the repeat, stating that there is a clot or other problem with the sample, but without giving the meaningless result. 8. Inappropriate and Unnecessary Transfusion (I&U) 67
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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
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3. Participation in Haemovigilance
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Figure 2 Number of reports sent per
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For the first time this year, SHOT
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4. SHOT 2009-2010 UK Transfusion La
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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 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: COMMENTARY Each year SHOT emphasise
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
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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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