SHOT Annual Report 2009 - Serious Hazards of Transfusion

9. Handling and Storage Errors (HSE)
Definition
Handling and Storage Errors comprise all reported episodes in which a patient was transfused with a blood
component or plasma product intended for the patient, but in which, during the transfusion process, the handling
and storage may have rendered the component less safe.
DATA SUMMARY
Total number of cases 196 Implicated components Mortality/morbidity
Red cells 146 Deaths due to transfusion 0
FFP 4
Deaths in which reaction was
implicated
Platelets 13 Major morbidity 0
Other 6
0
Unknown 27
Gender
Age
Emergency vs. routine and core
hours vs. out of core hours
Where transfusion took place
Male
Female
Unknown
92
88
16
18 years+
16 years+ to 18 years
1 year+ to 16 years
28 days+ to 1 year
Birth to 28 days
Unknown
Total
156
1
4
3
1
31
196
Emergency
Routine
Not known
In core hours
Out of core hours
Not known/applicable
38
126
32
19
38
139
ED
Theatre
ITU/NNU/HDU/Recovery
Wards
Community
Outpatient/day unit
Not known
4
7
11
98
0
7
69
Figure 9 illustrates the steady increase in HSE incidents reported to SHOT since 2003. A total of 196 cases were reported
in this category, none of which resulted in mortality or major morbidity. As the culture of reporting has developed, 2009
has shown a 41% increase in HSE reports compared with 2008.
Figure 9
Number of HSE cases 1996–2009
250
200
196
Number of reports
150
100
79
74
118
139
50
43
54
0
0
1996–97
0
1997–98
0
1998–99
0
1999–00
0
2000–01
0
2001–02
(15 months)
2003
Year of report
2004
2005
2006
2007 2008 2009
9. Handling and Storage Errors (HSE) 75