SHOT Annual Report 2009 - Serious Hazards of Transfusion

More documents

Recommendations

Info

Table 28 Categories of handling and storage errors Type of case 2008 2009 Technical administration error 9 12 Transfusion of expired red cells 45 31 Excessive time to transfuse 24 69 Cold chain error 61 84 TOTAL 139 196 Technical administration errors n = 12 There were 12 cases in which there were technical administration errors. Again this year there are 2 cases where a transfusion was continued despite the blood bag being pierced when inserting the administration set spike into the component port. Table 29 Technical administration error types Type of case No. Leaking component but transfusion continued 1 Blood given through incorrect solution giving set (includes 1 case of excessive time to transfuse + 1 case continued transfusion despite piercing the blood bag when changing the giving set) 11 Case 1 While changing an incorrect giving set the blood bag was inadvertently pierced Red cell transfusion was commenced in theatre using the wrong giving set. The recovery room nurse noticed the error and while changing the giving set pierced the blood bag at the inlet end. With the agreement of the anaesthetist the blood bag was patched with a gauze swab and tape. The ward staff discarded the blood when the patient returned to the ward. Transfusion of expired red cells n = 31 There were 31 cases in which expired blood was transfused to a patient. This demonstrates a 31% reduction in the number of cases reported in 2008. One aliquot from a paedipak was irradiated, issued and transfused despite being more than 14 days old. In 12 cases the blood had been issued (or was still available at issue) within 8 hours of the expiry date/time (2 units were issued within 30 minutes of the expiry date/time). Despite the staff being aware of the short expiry time, delays due to the patient’s condition or technical problems led to a further delay in commencing the transfusion. Seven cases involved the transfusion of platelets or thawed FFP or cryoprecipitate after the recommended expiry date/time. 76 9. Handling and Storage Errors (HSE)
Excessive time to complete administration of blood components n = 69 There were 69 cases reported in this category: this is the largest increase in reporting in the Handling and Storage chapter (> 150%) from 2008. In 22 cases the transfusion overran by less than 60 minutes (≤ 15 minutes in 4 cases). In a further 22 cases, the transfusion overran by between 60 and 120 minutes. In 13 cases the transfusion overran by more than 2 hours; in 5 cases the transfusion took up to 10 hours to complete (6 hours in 3 cases, 7 hours in 1 case and in a routine transfusion episode for anaemia 9 hours 40 minutes). In 7 cases the duration of overrun was not given. The majority of transfusions took place during core hours (79%) and were in routine transfusion episodes (67%). One event reported the results of an audit of ‘duration of transfusion’ which identified 12 units which were transfused to different patients over longer than the 4 hour recommended time period. Table 30 Breakdown of times of transfusion that took excessive time to run n = 47 NB not given in 22 cases Time period No. 08.00 to 20.00 34 20.00 to 00.00 8 00.00 to 08.00 5 Case 2 Expiry date checks are important especially prior to starting a transfusion A unit of blood was collected from the hospital transfusion laboratory at 17.55. The unit expired at midnight that night. The staff had problems with the infusion device occluding during the transfusion. The transfusion commenced at 18.00 and concluded at 03.40, a total transfusion time of 9 hours 40 minutes, resulting in transfusion of blood past the expiry date. The patient suffered no ill effects. COMMENTARY ■■ ■■ ■■ It is imperative that staff have the appropriate knowledge and understanding of technical issues when administering blood components, including the appropriate equipment requirements and the maximum time over which components can be administered after leaving controlled temperature storage (CTS). All staff should be aware that checking the expiry time is a critical part of the checking process at both issue and administration. The practice of issuing blood components, especially red blood cells, within 4 hours of their expiry time to reduce wastage levels should be discouraged. 9. Handling and Storage Errors (HSE) 77
Page 1 and 2:
Annual Report 2009 Affiliated to th
Page 3 and 4:
Requests for further information sh
Page 5 and 6:
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 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 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: 9. Handling and Storage Errors (HSE
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
Page 121 and 122: Table 42 Cases classified according
Page 123 and 124: Clinical details and transfused flu
Page 125 and 126: Cases in which RBC transfusion was
Page 127 and 128: exchange in patients with TTP. 43 I
Page 129 and 130: 15. Transfusion-Associated Dyspnoea
Page 131 and 132:
16. Post-Transfusion Purpura (PTP)
Page 133 and 134:
■■ The requirement to irradiate
Page 135 and 136:
Two incidents (both bacterial, desc
Page 137 and 138:
Viral and parasitic TTIs Since 1996
Page 139 and 140:
The most likely source of the organ
Page 141 and 142:
19. Autologous Transfusion Definiti
Page 143 and 144:
RECOMMENDATIONS There are no new re
Page 145 and 146:
Introduction and overall trends In
Page 147 and 148:
incident group O D negative units w
Page 149 and 150:
Table 47 Types of reactions for eac
Page 151 and 152:
always require notification by clin
Page 153 and 154:
21. Near Miss Reporting Definition
Page 155 and 156:
29 UK Resuscitation Council Emergen
Page 157:
24. Acknowledgements The Steering G
show all

SHOT Annual Report 2009 - Serious Hazards of Transfusion

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?