TRANSFUSION SCIENCE This year for the first time the report


includes a chapter with data on donor vigilance provided by the four UK Blood Services. This was compiled by a new working group and demonstrates the full reach of haemovigilance, from donor to recipient.


Key SHOT messages The four most serious adverse reactions: • Haemolysis contributed to death in five cases, including one caused by anti-Wra


one ABO-incompatible transfusion, and an infant death related to exchange transfusion for D-related haemolytic disease of the fetus and newborn


• Transfusion-associated circulatory overload contributed to death in seven cases, and major morbidity in 34


• Delayed transfusion contributed to death in six cases and major morbidity in five


• Acute transfusion reactionswere associated with severe reactions (major morbidity) in 86 patients.


Increased laboratory errors It should be noted that the number of laboratory errors is increased disproportionately by 12 reports affecting multiple patients (n=88) receiving components that had been out of temperature control. A United Kingdom Transfusion Laboratory Collaborative (UKTLC) survey in March 2015, in partnership with the National Blood Transfusion Committee, provided evidence of several issues including reorganisations in 100/178 (56.2%) laboratories, inability to fill vacancies, reduced resources (both financial and in personnel for training) and 35.7% of the workforce aged 50 years or more whose serological expertise will be lost on retirement.


Summary of main findings and cumulative results Errors account for 78% of all reports and some of these contributed to patient deaths.


ABO-incompatible red cell transfusions (n=7) These are ‘never events’ in England; in Scotland these would be reported as ‘red incidents’ through the Scottish National Blood Transfusion Service clinical governance system and/or those of the Health Board. ABO-incompatible red cell transfusions were associated with one death and one serious reaction in a patient with sickle cell disease (Chapter 6, Incorrect Blood Components Transfused [IBCT]). There were also six ABO-incompatible red cell transfusions administered to patients who had undergone allogeneic haemopoietic stem cell transplants (Chapter 23, Summary of Incidents Related to Transplant Cases). Although these are small numbers, near-


miss reporting shows that 288 additional patients were put at risk as the blood sample


416


If ‘yes’ to any of the above • Review the need for transfusion (do the benefits outweigh the risks?)


1 2 3


• Can the transfusion be safely deferred until the issue can be investigated, treated or resolved?


• Consider body weight dosing for red cells (especially if low body weight) • Transfuse one unit (red cells) and review symptoms of anaemia • Measure the fluid balance • Consider giving a prophylactic diuretic • Monitor the vital signs closely, including oxygen saturation


Fig 2. Transfusion-associated circulatory overload risk assessment/pre-transfusion checklist. a


Human factors in hospital practice Be safe! Use the bedside checklist


3Positive patient identification • Ask the patient to state name and date of birth


3Check identification of component against patient wristband 3Check the prescription 3Check the prescription


• Has this component been prescribed? • Is this the correct component?


b


3Check for specific requirements Blood transfusion bedside checklist


• Does the patient need irradiated components or specially selected units? Before each unit of blood is transfused, ensure you:


1 Check for blood component integrity 2 Check informed consent is documented 3 Confirm positive patient identification (PPID)


Now you may set up your safe transfusion


Fig 3. Examples of pre-transfusion checklists: a) modified five-point checklist recommended by SHOT in the Annual Report 2013; b) bedside checklist piloted in London and available throughout England.


AUGUST 2016 THE BIOMEDICAL SCIENTIST • No clots, leaks, damage, discolouration or expiry • Reason and risk/benefits explained? Alternatives? Information given? • Ask your patient to tell you their full name and DOB


4 Check unit tag against unit label, prescription, patient ID band and PPID 5 Perform observations


• Are there any specific transfusion requirements? • Baseline, after 15 minutes, end of transfusion, and as per local policy


was either taken from the wrong patient (wrong blood in tube), or the wrong unit was collected, but these errors were detected before an ABO-incompatible transfusion took place.


Such errors are serious whether or not


they result in a clinically important outcome; for example, as quoted by Dekker et al. “if catnapping while administering anaesthesia is negligent and wrongful, it is so whether


TACO checklist Red cell transfusion for non-bleeding patients


• Does the patient have a diagnosis of heart failure, congestive cardiac failure (CCF), severe aortic stenosis or moderate to severe left ventricular dysfunction? • Is the patient on a regular diuretic?


,


• Is the patient known to have pulmonary oedema? • Does the patient have respiratory symptoms of undiagnosed cause?


• Is the fluid balance clinically significantly positive? • Is the patient on concomitant fluids (or has been in the past 24 hours)? • Is there any peripheral oedema?


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60