SHOT Annual Report 2009 - Serious Hazards of Transfusion

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