TRANSFUSION SCIENCE
From donor to recipient: SHOT haemovigilance scheme 2015 update
The Serious Hazards of Transfusion scheme report for 2015 was published recently and is available on the SHOT website. In this brief update, Paula Bolton-Maggs and Dafydd Thomas focus on some key issues.
The Serious Hazards of Transfusion scheme report for 2015 was published recently. It is encouraging to note that the level of participation remains high, and that serious adverse reactions (SARs; ie those reactions resulting in serious harm or death) are rare. The scheme continues working towards a closer alignment with the Medicines and Healthcare products Regulatory Agency (MHRA) and reporting to the European Union (EU). From October 2015 the SHOT Working
Expert Group (WEG) took over assessment of adverse reactions, forwarding to the MHRA those that required inclusion in the returns to the EU. The MHRA serious adverse events have been integrated with the SHOT data into a single chapter, and the full MHRA report can be found in the 2015 Annual SHOT Report Web Edition. Some topics and additional material
will be found in the SHOT Web Edition. Subjects include those where reports are few and there are no new observations, and include post-transfusion purpura (PTP), transfusion-related acute lung injury (TRALI), complications related to cell salvage (CS), handling and storage errors (HSE), errors associated with the right blood nevertheless being transfused to the right patient (RBRP), the full report on incidents related to anti-D immunoglobulin administration (anti-D) and anti-D immunisation in pregnancy, alloimmunisation data, and an update of events in patients with haemoglobin disorders. Medical practice is under pressure.
THE BIOMEDICAL SCIENTIST AUGUST 2016
More than a third of NHS staff reported work- related stress in the 2015 staff survey. Emergency departments are struggling, two in five new consultant physician posts were not filled in 2015, a third of GP training places remain vacant, and overall funding is tight. Once again, the majority of SHOT reports follow mistakes (often multiple) in the
Near-miss incidents: potential outcomes Total 288 possible ABO-incompatible transfusions
Cumulative SHOT data show that about 33% of ABO-incompatible red cell transfusions cause death serious harm
So, a third, 96/288 of patients potentially harmed ABOi AB to O
AB to A or B B to O
A to B or vice versa A to O
0 20 40 11 15 46 54 The most dangerous 145 60 80 A to O = donor unit group A to recipient of group O etc. 100 120 140
Fig 1. Possible impact if 288 near-miss events (detected) had led to red cell transfusions. ABOi = report stated the blood group would be ABO-incompatible but did not specify.
415 160
Near-miss events demonstrate how our practice is not safe
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transfusion process (77.7%) related to human factors. We have observed a worrying number of adverse reactions and events related to poor communication and poor clinical decisions. Laboratory errors have increased and there are concerns that local investigations and root cause analyses are not being fully completed. The UK Transfusion Laboratory Collaborative survey completed in March 2015 confirmed that many laboratories are under pressure, with vacancies (some very longstanding) and increased workloads. Clinical reports also note similar issues. Information technology, when properly set up, can be a significant safety improvement but some of our incidents demonstrate inadequate validation resulting in dangerous errors.
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