SHOT Annual Report 2009 - Serious Hazards of Transfusion

More documents

Recommendations

Info

Cold chain errors n = 84 Table 31 Summary of cold chain related errors Type of error No. of cases Alarm related 5 Equipment failure 7 Delivery or transfer of components 10 Inappropriate storage of components 62 Returned to stock - a) When they should have been discarded b) Without/no/incomplete cold chain documentation/traceability 31 8 Returned to the satellite fridge when they should have been discarded 3 Stored inappropriately in clinical area, e.g. out of order refrigerator, transport box, non-validated transport box/storage, unknown 20 TOTAL 84 This year there were 84 HSE incidents which resulted from cold chain errors. This compares to 61 similar cases last year. Three cases involved paediatric patients – a 9-month-old baby and children aged 12 and 17. In 15 cases the age was not given. All other cases were in adults over 18 years of age. As reported in previous years, 58% of the incidents occurred in a routine setting, 20% were emergencies and 22% were unknown. Of the 84 cases, only 1 patient experienced a mild reaction, and this is discussed in more detail below. This year 12 equipment-related incidents were reported. In 5 of the cases staff failed to carry out the correct procedure following an alarm being set off on a refrigerator. The remaining 7 cases resulted either from a power failure or a suspected refrigerator alarm failure. Red cell components stored at inappropriate temperatures were subsequently transfused to a number of patients. In all, 81% (68/84) of the errors involved patients receiving 1 or more units of RBC, platelets (7 cases) and FFP (1 case) that had been either inappropriately transported or had been out of CTS for more than 30 minutes and then returned to CTS. One patient experienced a mild reaction after being transfused a unit of RBC which been out of CTS for 70 minutes. The unit was returned to stock and reissued to the same patient, when it should have been discarded. The patient fully recovered. The 2008 SHOT report provided updated advice on the ‘30 minute rule’: ‘A unit of RBC removed from CTS but not started within 30 minutes can still be administered provided the transfusion can safely be completed within 4 hours of leaving CTS’ (SHOT, 2009/MHRA). This applies regardless of how long the unit has been out of CTS prior to commencement of administration to the patient, providing the component has been stored appropriately during that time, i.e. NOT in the ward drug fridge. As a result of this advice SHOT no longer requires reporters to submit incidents highlighting an ‘Excessive time to start transfusion’ unless the overall transfusion was not completed within the recommended 4 hours (see learning points). Completion of transfusion within 4 hours can be difficult in neonates due to vascular access and fluid load (see Paediatric Cases, page 140). Recent BCSH guidelines have adjusted for this, stating, that ‘there should be no more than 30 minutes 78 9. Handling and Storage Errors (HSE)
etween removing the component from the CTS and starting the transfusion; nevertheless the transfusion itself should take no more than 4 hours’. 19 In 8 of the cases the time units had been out of CTS was unknown, owing to incomplete cold chain documentation. Some of these case studies are presented below. Case 1 Units of blood returned to stock despite alert warning staff of incorrect procedure Blood was removed from the central blood fridge using the Blood Track system for a patient requiring transfusion. The transfusion was postponed until the following morning and the unit of blood was returned to the fridge 37 minutes later. An alert came up on the screen stating the unit had been out of CTS for over 30 minutes so was unsuitable to be returned to store, but this was ignored by the HCA and the blood was placed back in the fridge. The shift BMS received an alert on the system in the laboratory; he was unable to leave the laboratory to fetch the unit, so he marked it on the system as unusable. The following morning the blood was removed for transfusion. The alert came up again but was ignored by the HCA and subsequently the unit of blood was transfused. The patient experienced no adverse reaction. Numerous incidents this year describe staff overriding or ignoring warning signals. These are described in more detail in the IT chapter (page 57). The use of the electronic blood tracking systems does not prevent errors occurring, particularly when practitioners use the override facility or ignore warning signals. Case 2 Incomplete documentation on how long units of blood were kept out of CTS Four units of blood were removed from issue on 28 th of the month at 20.45 for an emergency. Two of the units were transfused and 2 units were returned to stock on 29 th at 09.52. The correct paperwork tracking how long the units were kept out of CTS was not signed, so it was difficult to identify who was involved. With no evidence of a valid Chain of Controlled Storage, these units were then reissued and used for another patient. This patient suffered no ill effects. It is imperative that each member of laboratory, clinical and support staff is vigilant when undertaking their part in the transfusion process. It is important to ensure efficient bedside checks are performed and the necessary documentation is completed to verify the storage, transportation and administration of the blood through recorded identification. This forms part of an effective traceability matrix and aims to prevent inaccurate information being distributed. COMMENTARY on cold chain errors There has been a 38% increase in the number of cold chain errors reported in 2009; again this may be an example of improved reporting. This year has seen numerous incidents in which cold chain documentation has been incomplete resulting in components that may have been stored at inappropriate temperatures subsequently being transfused to patients. This year SHOT has received a number of reports in which multiple patients are included as one event. These reports make reference to multiple patients being transfused with components that should have been discarded because of incomplete cold chain documentation. They also refer to failures to follow SOPs when a refrigerator alarm was activated. This type of batched reporting results in underestimation of the number of actual errors affecting patients. Nevertheless, reporters are advised to take on board the learning points to aid practice. All staff should be reminded that they have a professional responsibility to practise safely, and to ensure that their knowledge and skills are kept up to date when participating in the transfusion process. Often there is an opportunity for the error to be identified early on in the process; however, this year some alarms and warnings have been ignored – perhaps owing to the lack of training or lack of understanding of the rationale behind the protocols and SOPs in use. 9. Handling and Storage Errors (HSE) 79
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 and 80: 9. Handling and Storage Errors (HSE
Page 81: Excessive time to complete administ
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

Create successful ePaper yourself

Delete template?

Save as template?