SHOT Annual Report 2009 - Serious Hazards of Transfusion

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Figure 10 Cumulative data 200 186 180 160 140 137 Number of reports 120 100 80 60 67 87 77 63 44 40 20 0 0 1996–97 0 1997–98 5 1998–99 12 1999–00 17 2000–01 2001–02 (15 months) 24 2003 2004 2005 2006 2007 2008 2009 Year of report While it is encouraging to note the increase in willingness to report cases, it is unfortunate that many of the reports contain insufficient detail to allow a good analysis of exactly where and when things are going wrong. What is apparent, however, is that exactly the same mistakes are being made by all staff groups this year as in previous years. They centre around failure to follow basic protocols, failure to take into account laboratory computer records, poor communication and poor decision making, underpinned by poor understanding. It is disconcerting to note that a number of reports imply that clinicians are waiting for the results of assessment of transplacental haemorrhage before deciding whether or not to request anti-D to cover potentially sensitising events, rather than giving an initial dose of anti-D and then requesting more if indicated. This is symptomatic of the distinct lack of ‘seamless’ protocols developed between laboratory and clinical areas, where clear guidance can be included and areas of responsibility can be clarified. A recommendation in the 2007 SHOT report related to the follow up of potentially sensitised patients, stating that the outcome should be reported to SHOT. It is anticipated that active follow-up of these cases by SHOT will become possible in future as the new web-based data collection system evolves. There were 3 case reports, not included in the total figures, in which women had become sensitised and developed immune anti-D even though testing and relevant prophylaxis had been carried out correctly. SHOT will continue to take this type of report, even though no ‘error’ has occurred. 86 10. Adverse Events Relating to Anti-D Immunoglobulin (Anti-D)
RECOMMENDATIONS New recommendations from this report Trusts must ensure that there is representation from midwives and obstetricians on hospital transfusion committees, with the aim of jointly drawing up straightforward local protocols for the request, issue and use of anti-D Ig based on well established national guidance. Action: HTCs Cases of late administration, omission, or inappropriate administration of anti-D immunoglobulin must be the subject of internal follow-up within Trusts/hospitals via established governance mechanisms. Action: HTCs, Trust/hospital CEOs Recommendations still active from previous years Year first made Recommendation (Previously Learning Points) Target Progress 2008 Trusts should ensure that robust systems under overall control of the hospital transfusion laboratory are in place, to ensure that anti-D Ig is issued on a named patient basis, to ensure appropriate use and to meet traceability requirements. HTCs 2007 2007 D-typing should be performed by the routine methodology available in the hospital transfusion laboratory, not by emergency techniques which may not be as robust. Obstetricians and midwives must be familiar with the national guidance for routine antenatal anti-D prophylaxis and the rationale behind it. National guidance regarding all anti-D prophylaxis should be standardised. There is a need for clear and unambiguous advice to ensure that all hospitals are able to develop local guidelines that reflect national consensus. Consultant haematologists with responsibility for transfusion, HTCs, HTTs NBTC, NHSBT Appropriate Use of Blood Group, IBMS, BBTS, BCSH, Royal Colleges of Midwives, O&G, GPs The NHSBT Appropriate Use of Blood Anti-D Working Group has developed anti-D modules for both clinical and laboratory staff as part of the Learn Blood Transfusion e-learning programme. 2007 There should be clinical follow up and retesting in six months of patients in whom anti-D administration has been delayed or omitted. The outcome should be reported to SHOT as well as internally within the Trust. Trust CEOs, consultant haematologists with responsibility for transfusion, HTCs, HTTs The new SHOT online reporting system will be collecting this data from 2010. 10. Adverse Events Relating to Anti-D Immunoglobulin (Anti-D) 87
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Annual Report 2009 Affiliated to th
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Requests for further information sh
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1. Foreword The Serious Hazards of
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2. SHOT - The UK Haemovigilance Sch
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3. Participation in Haemovigilance
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Figure 2 Number of reports sent per
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For the first time this year, SHOT
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4. SHOT 2009-2010 UK Transfusion La
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Update on 2008 recommendations Last
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Numbers of components issued In 200
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Table 10 Cumulative mortality/morbi
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Acute transfusion reaction (ATR) Th
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6. Key Messages and Main Recommenda
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Recommendation All pulmonary compli
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2005 Appropriate use of blood compo
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7. Incorrect Blood Component Transf
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Table 12 Summary of IBCT cases Type
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Major morbidity There were 2 cases
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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 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: Anti-D Ig given to the wrong patien
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
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19. Autologous Transfusion Definiti
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RECOMMENDATIONS There are no new re
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Introduction and overall trends In
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incident group O D negative units w
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Table 47 Types of reactions for eac
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always require notification by clin
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21. Near Miss Reporting Definition
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29 UK Resuscitation Council Emergen
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24. Acknowledgements The Steering G
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SHOT Annual Report 2009 - Serious Hazards of Transfusion

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