SHOT Annual Report 2009 - Serious Hazards of Transfusion

Major Morbidity
There was one patient that required venesection post transfusion.
Case 3
Entire adult unit of red cells given to infant
A request was made for top-up transfusion for a sick 1-year-old child with an Hb of 9.0 g/dL. A dose of 110 mL was
calculated and prescribed. An adult unit of blood was issued but nursing staff did not see the volume prescribed and
transfused the entire unit of blood (230 mL). This transfusion took place between midnight and 08.00. The error was
detected by laboratory staff when the patient’s post-transfusion Hb was 19 g/dL. The child required venesection.
The reporting hospital stated that the prescription chart could be improved to allow clearer prescription for paediatric
blood transfusion volumes. However, it is essential that all staff working in paediatrics are aware of the principles of
paediatric prescribing, based on body weight or surface area, whether administering blood components or pharmaceutical
agents.
Case 4 below describes the delayed and/or under-transfusion of a very anaemic neonate. It was thought that the
prolonged anaemia may have contributed to long-term morbidity in this infant.
Case 4
Delay in transfusing very anaemic neonate has long term consequences
A baby was delivered by CS and appeared unwell. There had been a massive transplacental haemorrhage and the
infant’s Hb was 4 g/dL. The clinicians did not know this result until 2 hours post delivery. There was then a further
delay of 4 hours before the baby was transfused, owing to misunderstandings and communication failures between
clinicians, portering staff and the transfusion laboratory. The team did not seem to know that neonatal ‘flying squad’
blood was available, nor did they ask for emergency blood even though the child was deteriorating. Blood was not
prescribed. A sample was eventually sent but there were portering delays both in taking the sample and collecting the
units. The total delay before transfusion commenced was over 4 hours. The baby became very sick and was transferred
to a tertiary centre. There was long-term morbidity with developmental delay which may have been in part due to the
prolonged period of extreme anaemia.
Figure 8
Cases of inappropriate and unnecessary transfusion 1996–2009
100
90
92
80
76
Number of reports
70
60
50
40
30
31
32
56
67
51 50
20
20
10
0
0 0 0 1
1996–97 1997–98 1998–99 1999–00
2000–01
2001–02
(15 months)
2003
2004
2005
2006
2007 2008 2009
Year of report
68 8. Inappropriate and Unnecessary Transfusion (I&U)