TRANSFUSION SCIENCE TACO Delays Pulmonary non-TACO
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UCT Overtransfusion
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HTR: Haemolytic transfusion reactions; UCT: Uncommon complications of transfusion; TACO: Transfusion-associated circulatory overload; PCC: Prothrombin complex concentrates.
Fig 2. Deaths related to transfusion (with imputability) reported in 2023. Imputability refers to the degree of certainty the event was caused by the transfusion.
cases (5/38, 13.2%). Of note, there were two deaths probably related to haemolytic transfusion reactions. The number of ABO incompatible (ABOi) transfusions has nearly doubled in 2023 to 10 ABOi events (6 were reported in 2022), of which 7 were ABOi red cell transfusions and 3 ABOi transfusion of fresh frozen plasma (FFP). One FFP ABOi occurred in 2011 as the result of a wrong blood in tube event, which was discovered and reported in 2023. Further details can be found in the Annual SHOT Report 2023.
SHOT highlighted 11 key SHOT messages in 2023, to address causal and contributory factors for safety incidents. Please see further detail in the main report.
Key SHOT recommendations 1 Addressing patient identification (PID) errors to enhance transfusion safety
In 2023, laboratory errors lead to 25/150 (16.7%) right blood, right patient (RBRP) PID errors, with the potential for adverse patient outcomes.
2 Safe staffing to support safe transfusions The results of the UKTLC survey 2022 showed increasing recruitment and retention issues within the transfusion laboratory workforce; with concerns raised relating to the number, suitability, and calibre of applicants for HCPC-registered roles.
3 Effective, timely communications to ensure safe transfusions Clear communication between the laboratory and clinical area is essential for timely and safe patient care. Interoperability between electronic systems is essential, and mechanisms should be in place to ensure all relevant
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information for patients under shared care is efficiently transferred between organisations.
Infected blood inquiry (IBI) The IBI was an independent, public, statutory inquiry established to examine the circumstances in which NHS patients were given infected blood and infected blood products, particularly in the 1970s and 1980s. The SHOT Steering Group and Working Expert Group members would like to acknowledge the scale of the tragedy and extend their heartfelt compassion. Several recommendations in the IBI report support haemovigilance, patient blood management, transfusion education, laboratory support and digital transformation within transfusion and align with the philosophy of SHOT. The IBI report has put the spotlight on haemovigilance, acknowledging the value of reporting and learning from incidents. In particular, recommendation 7e states: “That all NHS organisations across the UK have a mechanism in place for implementing recommendations of SHOT reports, which should be professionally mandated, and for
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monitoring such implementation.” SHOT is working with key stakeholders to formulate action plans for implementation of these recommendations across the UK. Figure 3 summarises the main themes from the safety messages and recommendations from the report. 4
Serious adverse reactions Adverse reactions were reported in a total of 628 cases, with most reported as febrile, allergic and hypotensive reactions (336/628, 53.5%). A total of 53 haemolytic transfusion reactions (HTR) were reported in 2023; 9 acute (AHTR), 31 delayed (DHTR) and 13 cases of hyperhaemolysis. Two deaths related to HTR were reported (imputability 2 – probable/likely). Both reactions occurred in patients with sickle cell disorder (SCD), one of which is described in case study 1.
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The most implicated antibodies in AHTR were anti-Jka
and anti-Wra each), and in DHTR was anti-Jkb (2/9 (8/31), in
contrast to previous years. In five DHTR cases, the antibody specificity implicated had been previously reported on the England-wide electronic antibody sharing database, therefore the reaction was potentially avoidable.
Laboratory key messages and learning points In 2023, laboratory errors and near misses accounted for 742/3,833 (19.4%) of all cases reported and laboratory errors accounted for 535/1,764 (30.3%) SHOT errors where the component was transfused to the patient. Most errors occurred at the testing step, which has occurred in three of the past four years (Fig 4). This highlights the need for robust training, education, and safety mechanisms to be in place for transfusion laboratory testing. One laboratory error contributed to a patient death, this is described in full in the Annual SHOT Report 2023 (page 132), and a summary is shown as case study 2. This case illustrates the impact
Case study 1 Fatal haemolytic transfusion reaction following unnecessary elective exchange transfusion
A patient with sickle cell disorder was scheduled for an exchange transfusion in advance of elective surgery. The patient was informed that the surgery had been cancelled and despite this being communicated to the patient in advance of the transfusion, this information was not communicated to the haematology team and the exchange transfusion went ahead. Five days later the patient presented at the ED with severe pain and symptoms consistent with a delayed HTR. The patient later collapsed and suffered a cardiac arrest.
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