Figures From the AnnuAl shot report 2011 - Serious Hazards of ...

Figures from the Annual SHOT Report 2011
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Figure 2.1
RTCs & countries reports per 1000 components issued by category
*Anti-D reports per 100 doses issued
1.00
Reports per 1000 components
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
Pathological reaction
Adverse event
Near miss
Anti-D*
Withdrawn
0.10
0.00
East
Midlands
RTC
East of
England
RTC
London
RTC
North
East RTC
North
West RTC
South
Central
RTC
South
East
Coast
RTC
South
West RTC
West
Midlands
RTC
Yorkshire
& The
Humber
RTC
Northern
Ireland
Scotland
Wales
RTC / country

Figure 2.2–2.5
2010 participation
Total reports per 1000 blood components issued
7.00
Figure 2.2 Low usage organisations
7.00
Figure 2.3 Medium usage organisations
6.00
6.00
Reports per 1000 components
5.00
4.00
3.00
2.00
1.00
Median = 1.21
Reports per 1000 components
5.00
4.00
3.00
2.00
1.00
Median = 1.09
0.00
P0019
P0031
P0057
P0107
P0187
P0221
P0217
P0014
P0005
P0114
P0181
P0099
P0058
P0015
P0144
P0154
P0158
P0212
P0174
P0160
P0063
P0069
P0070
P0011
P0085
P0036
P0211
Organisation
Figure 2.4 High usage organisations
P0108
P0215
P0050
P0077
P0166
P0198
P0169
P0096
P0170
P0004
P0161
P0110
P0067
P0120
P0145
P0090
P0213
P0163
P0093
P0098
P0052
0.00
P0165
P0116
P0220
P0104
P0081
P0068
P0216
P0208
P0018
P0180
P0043
P0026
P0027
P0197
P0138
P0079
P0117
P0061
P0040
P0078
P0119
P0086
P0222
P0101
P0084
P0037
P0141
Organisation
P0007
P0032
P0157
P0183
P0134
P0209
P0048
P0139
P0060
P0173
P0044
P0122
P0189
P0186
P0042
P0089
P0185
P0172
P0195
P0066
P0064
P0121
Figure 2.5 Very High usage organisations
7.00
7.00
6.00
6.00
Reports per 1000 components
5.00
4.00
3.00
2.00
Reports per 1000 components
5.00
4.00
3.00
2.00
1.00
Median = 0.96
1.00
Median = 0.69
0.00
P0013
P0047
P0164
P0051
P0115
P0155
P0109
P0097
P0055
P0100
P0218
P0153
P0045
P0010
P0038
P0054
P0075
P0150
P0092
P0041
P0113
P0039
P0088
P0003
P0029
P0206
P0188
P0149
P0147
P0159
P0082
P0203
P0214
P0156
P0146
P0056
P0020
P0219
P0148
P0091
P0049
P0210
P0073
P0006
Organisation
0.00
P0046
P0118
P0009
P0152
P0033
P0151
P0133
P0102
P0095
P0112
P0012
P0205
P0171
P0202
P0080
P0204
P0001
P0168
P0017
P0167
P0035
P0074
P0207
P0182
P0059
P0199
P0201
P0137
P0083
P0072
P0028
P0162
P0200
P0136
P0106
P0103
P0065
P0034
P0062
P0016
P0140
P0105
P0053
P0123
Organisation

Figure 4.1
Cases reviewed in 2011 (excluding near miss and instances where the patient
received a correct component despite errors having occurred – RBRP)
n=1815
HSE 325 (17.9%)
I&U 149 (8.2%)
Anti-D 249 (13.7%)
IBCT 247 (13.6%)
PTP 2 (0.1%)
CS 42 (2.3%)
PUCT 2 (0.1%)
TAD 35 (1.9%)
TACO 71 (3.9%)
TRALI 12 (0.7%)
HTR 94 (5.2%)
ATR 587 (32.3%)

Figure 4.2
Cumulative data for SHOT categories 1996/7-2011
n=9925
CS: Cell salvage and autologous transfusion
TTI: Transfusion-transmitted infection
PTP: Post-transfusion purpura
PUCT: Previously uncategorised complication
of transfusion
Pathological reactions which may not be preventable
ATR: Acute transfusion reaction
TAD: Transfusion-associated dyspnoea
HTR: Haemolytic transfusion reaction
TA-GvHD: Transfusion-associated graft
vs host disease
TRALI: Transfusion-related acute lung injury
Probably or possibly preventable by
improved practice and monitoring
TACO: Transfusion-associated circulatory
overload
Anti-D: Anti-D errors
HSE: Handling & storage errors
I&U: Inappropriate & unnecessary
Adverse events caused by error
IBCT: Incorrect blood component transfused
0 500 1000 1500 2000 2500 3000 3500
Number of reports

Figure 4.3
Incorrect blood components transfused (IBCT) either due to wrong component (WCT) or where special requirements were not
met (SRNM), handling and storage errors (HSE), showing the number that resulted in ABO-incompatible transfusions
800
Number of reports
700
600
500
400
300
200
100
0
63
45
13
5
I&U
HSE
IBCT-SRNM
All Other IBCT-WCT cases
ABO Incompatible red cell transfusions
31
14
29
43
56
54 79
74
83
118
188
107
117 154
173
143
23
141
128
24
131 38
108
111
11
50
93
7
22
153
93
119
135
64
72
100
114
82
101
107
82 59
85
36 26 34
17 22 26
19 10 8 12 10 14 4 12
107
303
1996-97 1997-98 1998-99 1999-00 2000-01 2001-02
(15 months)
324
372
398
67
323
51
332
50
2003 2004 2005 2006 2007 2008 2009 2010 2011
Year of report
477
76
139
570
92
196
549
110
239
721
149
325

Figure 9.1
Total Cases of inappropriate and unnecessary, and delayed or under-transfusion 1996-2011
(Note: reports of delayed transfusions have only been collected for 2010 onwards)
160
140
I&U Delayed
All other I&U Cases
120
Number of reports
100
80
60
108
137
40
20
0
0 0 0
1
20
31 32
56
67
51 50
1996/97 1997/98 1998/99 1999/00 2000/01 2001/02* 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year of report
76
92
2
12

Figure 12.1
Cumulative data
250
241
249
200
186
Number of reports
150
100
67
87
77
63
137
50
44
0
5
12
17
24
1998/99 1999/00 2000/01 2001/02* 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year of report

Figure 13.1
Cases of ATR since 1996
600
587
500
510
Number of reports
400
300
200
300
400
114
100
24 24
34 33 31
48
39 34
68
85
0
1996/97 1997/98 1998/99 1999/00 2000/01 2001/02* 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year of report

Figure 13.2
Reaction by component type
Percentage of reactions
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
22 10
4
8 3
17
2
5
9 2
52
284
15
67
41
11
26
2
Red cells Platelets Plasma Multiple components
Component type
2
2
3
Febrile
Allergic
Anaphylactic
Mixed allergic/febrile
Hypotensive
Unclassified
Each star represents a case of:
HLA matched platelets
Solvent detergent plasma
Methylene blue plasma

Figure 14.1
Number of cases of HTR reviewed since 1996
60
55
50
47
47
43
40
39
40 40
Number of reports
30
23
25
30
24
25
28
34
23
20
10
0
1996/97 1997/98 1998/99 1999/00 2000/01 2001/02* 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year of report

Figure 14.2
Interval in days between administration of the implicated transfusion and signs or symptoms of a DHTR
6
5
5
4
4
4
Number of patients
3
2
2
3
1
1 1
1
1 1 1
0
2 3 5 6 7 8 9 10 11 12 26
No. Days

Figure 15.1
Number of suspected TRALI cases and deaths at least possibly related to TRALI by year of report
36
35
30
Number of deaths
Suspected TRALI reports
33
25
23 23
24
Number of reports
20
15
14
16
18
13
17
21
15
12
10
9
10
7 7
5
0
2 2
4 4
3
3
2
1 1
0
2
1 1
1996/97 1997/98 1998/99 1999/00 2000/01 2001/02* 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year of report

Figure 16.1
Number of cases of TACO reported to SHOT each year
80
70
71
60
Number of reports
50
40
30
34
40
20
18
10
3
0
2007 2008 2009 2010 2011
Year of report

Figure 17.1
Number of cases of TAD reported to SHOT each year*
* TAD was introduced as a SHOT reporting category in 2009.
40
35
35 35
30
Number of reports
25
20
15
10
5
4
1
0
2008 2009 2010 2011
Year of report

Figure 18.1
Number of cases of PTP reported to SHOT each year (HPA antibody positive)
12
11
10
10
9
Number of reports
8
6
4
5
3
2
2
2
2
2
1
1
1
0
0
0
0
1996/97 1997/98 1998/99 1999/00 2000/01 2001/02* 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year of report

Figure 19.1
Number of cases of TA-GvHD reported to SHOT each year
4.5
4
4 4 4
3.5
3
Number of reports
2.5
2
1.5
1
1
0.5
0
0
0 0 0 0 0 0 0 0 0 0
1996/97 1997/98 1998/99 1999/00 2000/01 2001/02* 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year of report

Figure 20.1
Number of bacterial TTI incidents, by year of report and type of unit transfused (Scotland included from 10/1998)
6
5
Platelets
Red cells
4
Number of reports
3
2
1
0
1996-97 1997-98 1998-99 1999-00 2000-01 2000-02
(15 months)
2003 2004 2005 2006 2007 2008 2009 2010 2011
Year of report

Figure 20.2
Number of viral and parasitic TTI incidents, by year of report and infection type (Scotland included from 10/1998)
6
Number of reports
5
4
3
2
HAV
HBV
HCV
HEV
HIV
HTLV
Malaria
1
0
1996/97 1997/98 1998/99 1999/00 2000/01 2001/02* 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year of report

Figure 21.1
Autologous adverse events
45
42
40
35
Number of reports
30
25
20
15
28
14
15
10
5
0
2008 2009 2010 2011
Year

Figure 22.1
Trends in paediatric reports 2007-2011
a. Total numbers of paediatric reports b. Paediatric SRNM reports
Number of reactions
Number of reports
140
≤ 28 days
120 >28 days to

Figure 22.2
Percentages of paediatric and total reports in each category
(% numbers have been corrected to the nearest whole number)
45%
40%
Paediatric percentages
Total percentages
40%
35%
32%
Percentage of reports
30%
25%
20%
15%
13% 13%
12%
18%
14%
10%
5%
0%
7%
7%
9%
8%
4%
2%
5%
1% 1%
4% 4%
2%
1%
2%
2%
0% 0% 0% 0% 0% 0%
IBCT-WCT IBCT-SRNM I&U HSE Anti-D ATR HTR TRALI TACO TAD PTP PUCT TAGvHD CS
Category

Figure 22.3
Paediatric ATR reports
a. Comparison of proportions of adult and paediatric b. Percentages of reaction types for each
ATRs due to different components
component for paediatric reports
Percentage of reports
100%
90%
80%
70%
60%
50%
40%
30%
7
44 2 1
119
369
26
Red cells
Platelets
FFP
Other (cryo)
Multiple components
Percentage of reactions
100%
90%
80%
70%
60%
50%
40%
30%
2
1
1
2
13
1
1
4
14
2
2
1
2
7
16
Febrile
Allergic
Anaphylactic
Mixed allergic/febrile
Hypotensive
Unclassified
20%
10%
19
20%
10%
6
1
20
0%
Adults
Children
0%
Red Cells Platelets Plasma Total
Component type

Figure 24.1
MHRA divisional integration for blood safety and quality regulation

Figure 24.2
Confirmed SABRE reports by RTC Region 2005 - 2011
(minus excluded reports)
1200
No. of reports
1000
800
600
400
Serious adverse events
Serious adverse reactions
Total
200
0
Blood Establishments
Scotland
N Ireland
Wales
Private hospitals
North East
North West
Yorkshire & Humber
East Midlands
West Midlands
East of England
London
South Central
South West
South East
Region

Figure 24.3
All UK SABRE reports 2005 - 2011 (minus exclusions)
1600
1400
1200
Serious adverse reactions
Serious adverse events
Total
No. of reports
1000
800
600
400
200
0
2005 2006 2007 2008 2009 2010 2011
Year

Figure 24.4
SABRE reports excluded from EU Commission annual summary each year
350
300
250
No. of reports
200
150
100
50
0
2005 2006 2007 2008 2009 2010 2011
Year

Figure 24.5
Hospital blood bank critical and major deficiencies – Top 5 deficiencies by %
CAPA
Investigation of anomalies
Defect category
Personnel issues - training
Duties of key personnel
Change control
0 2 4 6 8 10 12 14
% of total critical/major deficiencies cited

Figure 25.1
The transfusion cycle shows the vital importance of a correct sample and can be summarised as: