SHOT Annual Report 2009 - Serious Hazards of Transfusion

More documents

Recommendations

Info

Learning points ■■ Blood components should be removed from CTS only when the transfusion is ready to commence, i.e. the patient is available, venous access has been checked and the component has been prescribed. ■■ Fridges should be cleaned at regular intervals by trained and competency-assessed individuals and should be well documented in the local SOP. It is the responsibility of the laboratories to monitor that this is being done as per the SOP and take effective CAPA if it is not being carried out effectively. 28 ■■ Red blood cell components should not be issued when there are 4 hours or less before their expiry time. ■■ The expiry date must be checked by the laboratory staff before the component leaves the hospital transfusion laboratory and by the clinical staff as part of the pre-administration check before the component is transfused. SHOT recommends that staff should be advised to cease the transfusion at midnight as the manufacturers’ product liability ceases at midnight on the day of expiry. 28 The following learning points from previous reports remain pertinent: ■■ ■■ ■■ ■■ Only staff who have been competency-assessed must be involved in any part of the transfusion process. Use of electronic blood tracking systems does not prevent errors occurring, particularly when staff use the override facility or ignore warning signals and alarms. The expiry date must be checked by the laboratory staff before the component leaves the hospital transfusion laboratory and by the clinical staff as part of the pre-administration check before transfusion. Transfusion of a blood component should be completed within 4 hours of leaving controlled temperature storage (CTS). ■■ 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. In this scenario the case is not reportable either as a Serious Adverse Event (SAE) to MHRA or as a handling and storage error to SHOT. ■■ A unit that has not been transfused CANNOT be returned to CTS for storage or reissue if it has been out of CTS for more than 30 minutes. If a unit is replaced into CTS after 30 minutes, then this is reportable as an SAE to MHRA, and if subsequently transfused then it is also reportable to SHOT. RECOMMENDATIONS ■■ Maintaining cold temperature storage conditions and guaranteeing the capture of valid and accurate monitoring data are the responsibility of all staff involved in the storage, transportation and administration of blood components. Clear guidance should be provided regarding the removal (and return should it not be required) of every blood component from validated storage areas. Action: HTCs, HTTs ■■ As part of the competency-assessment process the importance of checking the expiry date during the collection/final patient identity checks must be emphasised to all practitioners. Action: HTTs 80 9. Handling and Storage Errors (HSE)
10. Adverse Events Relating to Anti-D Immunoglobulin (Anti-D) Definition An adverse event relating to anti-D Ig is defined as an event relating to the prescription, administration or omission of anti-D Ig which has the potential to cause harm to the mother or fetus immediately or in the future. DATA SUMMARY Total number of cases 186 Implicated components Mortality/morbidity Gender Age Red cells Deaths due to transfusion 0 FFP Deaths in which reaction was implicated Platelets Major morbidity 1 Anti-D Ig 186 Potential for major morbidity 127 Unknown Emergency vs. routine and core hours vs. out of core hours Where transfusion took place 0 Male Female Unknown 0 186 0 18 years+ 16 years+ to 18 years 1 year+ to 16 years 28 days+ to 1 year Birth to 28 days Unknown Total 183 3 0 0 0 0 186 Emergency Routine Not known In core hours Out of core hours Not known/applicable 186 186 ED Theatre ITU/NNU/HDU/Recovery Wards Community Outpatient/day unit Not known 154 32 This section describes the main findings from 186 completed questionnaires. However, 1 of the submitted questionnaires refers to a hospital audit involving 11 different patients, so the number of individual cases considered in this chapter is actually 196. The reports are broken down into the reporting categories shown in Table 32. Under current haemovigilance legislation, 2 adverse events related to anti-D immunoglobulin are reportable as ‘SHOT-only’. Adverse reactions are reportable under the yellow card system for batched pharmaceutical products. Table 32 Reporting categories Category of adverse event Number of cases Omission or late administration of anti-D immunoglobulin 127 Inappropriate administration of anti-D immunoglobulin 62 to a RhD positive patient to a patient with immune anti-D to a mother of a RhD negative infant to the wrong patient 27 20 6 9 Wrong dose of anti-D immunoglobulin given according to local policy 6 Administration of expired or out of temperature control anti-D Ig 1 TOTAL 196 10. Adverse Events Relating to Anti-D Immunoglobulin (Anti-D) 81
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 and 82: Excessive time to complete administ
Page 83: etween removing the component from
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?