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BLOOD MANAGEMENT


Serious Hazards of Transfusion – A continuing need for improvement in practice


Paula HB Bolton-Maggs, medical director at SHOT, describes the fi ndings of the organisation’s latest annual report and its key recommendations.


T


he majority of reported transfusion incidents are caused by error.


In 2013 SHOT (Serious Hazards of Transfusion) received more than 3,500 reports, with nearly 100% participation by UK NHS hospitals. The Annual Report for 2013 was published on 9 July, 2014, and is available at www.shotuk.org.


As in all previous years, errors (human factors) were responsible for the majority of reports: 77.6%. Blood and its components are very safe, with no new transfusion-transmitted infections confi rmed in 2013, but the transfusion process is not yet safe.


Patient safety is put at risk because of mistakes. A review of 220 reports where the patient received an incorrect blood component demonstrated that multiple errors are common: the median number of errors was three (range one to fi ve). Many of these could, and should, have been detected if the fi nal bedside check had been done correctly, and the use of a fi ve-point checklist or aide memoire at the fi nal bedside check would detect many of the pre-transfusion errors.


Airline pilots would not consider bypassing their checklists prior to take-off and there is as much justifi cation for this transfusion checklist. Such human factors are widespread in medical practice; our tendency to improvise or fi nd workarounds must be balanced by adherence to essential steps.


Observational audit demonstrates that healthcare staff often do not, but also are sometimes unable to, follow the recommended


70 | national health executive Sep/Oct 14


procedures, particularly correct positive identifi cation of the patient and labelling of blood samples at the patient’s side [1]. Although technological solutions can be of benefi t, full end-to-end computer systems (with more robust identifi cation procedures, including barcoding) have not been widely adopted – mainly because of the expense.


SHOT therefore recommends that the multi- step, multi-disciplinary transfusion process (with nine critical steps) needs review and redesign to try to reduce the errors.


ABO-incompatible transfusions


ABO-incompatible transfusions are the most feared complication resulting from error, as death may result. There were nine ABO- incompatible red cell transfusions reported in 2013, one contributing to death of a patient and three to major morbidity (defi ned by admission to intensive care or serious complications such as the development of renal failure).


However, a review of cumulative SHOT data (over 17 years) shows that two-thirds of all ABO-incompatible red cell transfusions are not associated with adverse outcomes. About a third of all SHOT reports are of ‘near miss’ events, many related to ‘wrong blood in tube’ (where the name and identifi cation details on the tube are not those of the patient whose blood is in the tube). In 2013, at least 125 of these would have resulted in ABO-incompatible transfusions had they not been detected. There is therefore a greater risk of this than might be appreciated from the actual events. Currently only those which cause death or serious harm


are reportable as ‘never events’.


SHOT now recommends that NHS England should accept reports of all ABO-incompatible transfusions, including those where no harm was done.


Training in human factors


The continued rate of error, despite the introduction of guidelines, protocols and competency assessments, reinforces the need for better understanding of and training in human factors, as recommended by the House of Commons Health Committee in 2009 [2] and many other organisations together with the publication of the Human Factors Concordat [3].


The NHS Litigation Authority is no longer monitoring adherence to transfusion standards.


Therefore, SHOT recommends that the management of blood and blood component transfusion should be included as a specifi c standard by the Care Quality Commission, as is done for medicines.


Transfusion errors and delays


There were 22 deaths in 2013 where transfusion (17 cases) or delay in transfusion (5 cases) played a part. SHOT has been monitoring delays in transfusion since 2010 as a result of a Rapid Response Report from the former National Patient Safety Agency [4] which required hospitals to review their arrangements and report delays. There have been 69 instances of delay reported over the


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