Patient safety Delays TACO Pulmonary non-TACO IBCT-WCT
HTR PCC
FAHR UCT
0 0
2 2
4 4
TACO: Transfusion-associated circulatory overload; IBCT-WCT: Incorrect blood component transfused - wrong component transfused; PCC: Prothrombin complex concentrates; HTR: Haemolytic transfusion reactions; FAHR: Febrile, allergic and hyptotensive reactions; UCT: Uncommon complications of transfusion
Fig 2. Deaths related to transfusion (with imputability) reported in 2022. Imputability refers to the degree of certainty the event was caused by the transfusion.
10 15 20 25 30 35 40
0 5
0 5
Delays
10 15 20 25 30 35 40
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 IBCT-WCT
10 15 20 25 30 35 40
TACO Fig 3. Transfusion-related deaths 2010-2022.
0 5
0 5
Non-TACO HTR
0 5
10 15 20 25 30 35 40
Number
10 15 20 25 30 35 40
6 0 6
0
8 2 8
2
10 10
4 4
12 12
6 6
14 14
8
Definite/certain Likely/probable Possible
0 2
using human factors, principles-based incident investigations and appropriate mitigating measures implemented.
l Learning from near misses: Reporting and investigating near misses helps identify and control risks before actual harm occurs, providing valuable opportunities to improve transfusion safety.
4 6 8
10
l Shared care: Clear, timely and comprehensive communication between all teams and hospitals involved in patient care is vital in ensuring patient safety. Robust and transparent processes must be in place for safe and effective transfer of information at all points in the patient-care pathway.
10 8 10 12 12 14 14
The 2022 Annual SHOT Report has four main recommendations: 1. Appropriate management of anaemia with effective patient blood management and safe transfusion decisions are vital to improve safety.
2. Well-resourced systems, with adequate numbers of trained staff supported by technology and automation help ensure safe transfusions.
3. System-focused interventions to address gaps identified during incident investigations must be implemented for a sustained improvement.
4. Learning from excellence and day-to-day events will support a proactive approach to safety.
2021 2022 FAHR Other ABOi deaths (2) ABOi (4) IBCT-WCT (55)
Wrong patient transfused and wrong group transfused
Near miss IBCT-WCT (89) Wrong patient and wrong group cases Near miss WBIT samples (890) Fig 4. ABO-incompatible (ABOi) transfusions and events that had the potential to lead to ABOi in 2022. 46
www.clinicalservicesjournal.com I February 2024
ABOi: ABO-incompatible; IBCT-WCT: Incorrect blood
component transfused - wrong component transfused; WBIT: Wrong blood in tube
Deaths, major morbidity and ABO–incompatible transfusions In 2022, there were 35 deaths related to transfusion (identical to 2021), of which three were definitely due to the transfusion (imputability 3), see Figure 2. The SHOT figures for 2022 translate to a risk of death in the UK of 1 in 63,563 (1.57 per 100,000) components issued and the risk of serious harm is 1 in 15,449 (6.47 per 100,000) components issued. For the first time, delays in transfusion contributed to the highest number of deaths, 13/35 (37.1%), with transfusion-associated circulatory overload (TACO) contributing to 8/35 deaths (22.9%) as shown in Figure 3. Of note, there were two deaths following inadvertent ABO-incompatible (ABOi) red cell transfusions, both of which were totally preventable. A total of six ABOi events were reported in 2022,
of which five were ABOi red cell transfusions (all due to clinical errors). These errors resulted in two patient deaths; in both cases the primary error was at component collection. There was one case of major morbidity following an ABOi due to an administration error. There was one ABOi transfusion of fresh
12
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