BLOOD MANAGEMENT
four years, with 10 (14.5%) resulting in the death of the patient. The causes are varied but include failure by junior doctors to recognise signs of haemorrhage, poor communication and handover together with care by serial clinical teams, failure to identify patients properly, and slow response in critical situations. One patient who survived cardiac arrest due to blood loss and anaemia had been ‘stacked up’ in an ambulance for three hours and then waited in the emergency department for a further two hours before being assessed. Another patient who suffered cardiac arrest after haemorrhage has survived but with hypoxic brain damage.
Transfusion reactions that may not be preventable (reminding clinicians to ensure that every transfusion is really necessary)
Transfusion-associated circulatory overload (TACO) continues to be a significant cause of death (12 patients) and major morbidity (43 patients). Some of these should be preventable with appropriate pre-transfusion assessment: for example, elderly patients with risk factors such as renal impairment. SHOT recommends that patients should be carefully reviewed after each unit transfused to avoid this (‘don’t give two without review’).
The most common non-error and unpredictable events each year are acute allergic-type reactions
(320), which emphasises the importance of monitoring every patient during every transfusion. Haemolytic transfusion reactions (other than those due to ABO-incompatibility) can also cause death or serious complications. Every year patients with sickle cell disease are over-represented in these reports.
Since an increasing number of transfusions occur as outpatients or day case procedures, patients are at risk of developing adverse reactions after discharge. In addition, teams in primary care need education and training about indications for transfusion (such as use of iron therapy in iron deficiency) and also in the possible complications of transfusion.
SHOT recommends that patients should receive written information about possible adverse reactions after transfusion, and a contact telephone number.
Despite the incidents, overall blood and blood component transfusion in the UK is very safe. What are the current risk estimates for blood transfusion? The risk of viral transmission from donated blood is very low (one in 1.3 million for hepatitis B virus, one in 29 million for hepatitis C and one in 7.1 million for HIV). The risk of receiving a wrong component is much higher, at one in 48,000 components issued, and of receiving ABO-incompatible red cells is one in 263,000 components issued.
Adverse incident reporting for transfusion has led to a greater recognition of the risk of error.
The human factors issues described for transfusion feature across all of medical practice and more needs to be done to help medical and nursing staff to understand their vulnerability.
References
1. Alimam S, Hafez S, Pendry K, Bolton- Maggs PHB: Wrong blood in tube – where does the process go wrong? Transfusion medicine 2014, 24:191. 2. House of Commons Health Committee : Patient Safety 6th report of session 2008- 2009 Volume 1.
3. NHS England : Human factors in healthcare – a concordat from the National Quality Board. 4. National Patient Safety Agency: NPSA Rapid Response Report RRR017: ‘The transfusion of blood and blood components in an emergency’.
Paula HB Bolton-Maggs
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opinion@nationalhealthexecutive.com
national health executive Sep/Oct 14 | 71
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