Patient safety


frozen plasma (FFP) due to a laboratory error at component selection. A further 19 potential ABOi transfusions were avoided because errors were detected prior to transfusion. Figure 4 shows a summary of potential outcomes resulting from ABO-compatibility errors in the transfusion pathway.


Most ABOi errors were compounded by a lack


of reliable, accurate patient identification, plus the influence of staffing issues with suboptimal skill mix, high workload, knowledge gaps, decision fatigue and assumption bias.


Serious adverse reactions Serious adverse reactions were reported in a total of 571 cases. As in previous years, febrile, allergic and hypotensive reactions (FAHR) remain the most commonly reported reactions 294/558 (52.7%). When laboratory investigations are requested for suspected FAHR, these should be tailored to the reaction type and if severe enough for transfusion to be discontinued, repeat compatibility testing should be performed (except in cases with purely allergic features). Laboratory and clinical staff should have


clear lines of communication in suspected reactions to allow for all feasible causes to be investigated without introducing unnecessary delay or resource use. Updated guidance on the investigation and treatment of acute transfusion reactions has been published by the British Society for Haematology in 2023, and should be used to guide decision making.3 FAHR reactions are unpredictable and largely


unpreventable, illustrating the importance of giving transfusion only when there is no suitable alternative. Transfusion decisions must be made after considering risks and benefits to patients. Where transfusions are concerned, less is often more. In 11 cases, the reporter deemed that transfusion was not clinically indicated according to the relevant BSH guidelines. In a further 28 cases this was ‘unknown’ and in another seven cases, not stated. There was one death possibly related to


transfusion. A patient with relapsed leukaemia suffered an allergic reaction during a platelet transfusion, followed by airway obstruction requiring intubation and cardiac arrest. Prior to the transfusion the patient was gravely unwell, being managed in the intensive care unit and had recently received emergency chemotherapy. Various factors may have contributed to the acute deterioration and outcome in this patient. While most are minor, anaphylaxis can be


life-threatening, and this emphasises the need to ensure that transfusion is only given when clinically indicated and there is fully informed patient consent. Suboptimal management of acute transfusion reactions continue to be reported,


Case study 1


Collection error and lack of positive patient identification leads to an ABOi transfusion


A patient received an ABOi transfusion during a major haemorrhage (MH) post-surgery. The patient was group O D-negative and was inadvertently given B D-positive. A unit of red cells was collected by a porter from the issue refrigerator, but this was for another patient on a different ward. None of the details on the issue label/compatibility label were checked. Soon after, the porter realised the error and reported to laboratory staff, but the red cell unit had


Case study 2


Unnecessary investigations for an allergic reaction


A patient requiring regular transfusions, who had a history of allergic reactions in other settings, developed rash, urticaria, facial swelling and mild hypotension after 60mL of the third unit of red cells had been transfused. Transfusion was discontinued, they were given an


antihistamine and hydrocortisone and symptoms settled. They were investigated with IgA levels, mast


cell tryptase, repeat group and screen, direct antiglobulin test and blood cultures, none of which showed any abnormality.


already been transfused. BloodTrack (electronic patient identification) was available but not utilised and ward staff did not carry out any pre- administration checks. The emergency response team were not trained to use BloodTrack. The ward staff were inexperienced in dealing with MH and this event was very unusual and traumatic for those involved. The patient died on return to theatre and the death was attributed to complications of surgery.


Case study 3


Delayed administration of anti-D Ig due to procedural and patient factors


A pregnant D-negative patient had a procedure, and therefore potentially sensitising event, at 12+1 weeks. Anti-D Ig was issued but not administered before the patient was discharged. The ward staff realised the patient required the anti-D Ig and arranged for it to be administered two days after the procedure. The


particularly the inappropriate use of antihistamine and/or steroids to treat febrile reactions (in 46.9% of cases). There is a lack of selectivity in investigations


following the event, with compatibility testing frequently performed unnecessarily following allergic reactions. The key message remains the need to use the patient’s symptoms and signs to distinguish febrile from allergic reactions and to tailor investigation and management accordingly. An antihistamine with or without steroid continues to be used inappropriately to treat reactions with only febrile/inflammatory type symptoms and/or signs. In addition to no evidence


patient then informed the clinical team that they had a positive lateral flow COVID-19 test and so were unable to attend the appointment. Confirmatory COVID-19 PCR testing was negative two days later and the patient attended for the anti-D Ig injection, four days post procedure.


of benefit, the repeated use of steroids may further immunosuppress already immunocompromised patients and increase the risk of side effects such as infection. Laboratory investigations should be tailored to


the reaction type. If a febrile reaction is sufficiently severe to warrant discontinuing transfusion completely, compatibility testing should be repeated. Repeat compatibility testing is not required in reactions with purely allergic features.3 Transfusion was discontinued completely in


95/132 (72.0%) febrile reactions. In 22 of these, there was no mention of repeat compatibility testing. Of the 117 reactions with purely allergic features,


February 2024 I www.clinicalservicesjournal.com 47


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