TRANSFUSION SCIENCE


non-transfusion pathology disciplines can have on patient transfusion outcomes and their overall safety. There were seven cases where laboratory errors contributed to major morbidity, four cases of IBCT-SRNM causing sensitisation to the K antigen in patients of childbearing potential, and three cases of delays, two of which caused admission to the intensive care unit or high dependency unit and one case where a patient went into peri-arrest before being given red cells.


n Errors in the care of transplant patients


There were 28/535 (5.2%) laboratory errors which led to the wrong ABO/D group being transfused to transplant patients. These errors have more than doubled from 2022, where 13 cases occurred. Information technology was stated as an influencing factor in 27/28 cases and included lack of functionality in LIMS for transplant patients (16/28), LIMS flags not heeded (6/28), alerts not added or added incorrectly to LIMS (4/28) and failure to consult the historic record (1/28). Further errors occurred where shared care of patients between transplant centres and the patient’s local hospital introduced communication errors. Communication is critical for the management of transfusion in transplant patients, particularly where there is shared care across multiple organisations.


n Abbreviated and accelerated training


A concerning trend of ‘abbreviated and accelerated training’ has been observed within reports submitted to SHOT, in which staff are being allowed to work alone and outside of routine hours with only selected competency assessments completed. This abbreviated training is being necessitated due to a high staff turnover and problems with recruitment and retention, as evidenced by the UKTLC survey 2022. Incomplete training may be contributing the high level of testing errors that are observed within SHOT data. In these circumstances there may also be a delay in receiving additional training required, as once a staff member is ‘signed off’ for lone working they are traditionally compliant with all training requirements.


n Lone working


Laboratory data in 2023 showed that errors occur at a disproportionate rate when individuals were lone working. Of the 431 reports that provided an answer, 160/431 (37.1%) reports indicated the staff member was lone working. The UKTLC survey 2022, indicated that 45.9%


Case study 2 Incorrect blood film review procedure contributes to patient death (imputability 2: probable)


A biomedical scientist who was not trained on full blood count (FBC) validation reviewed a sample with Hb of 39g/L, white cell count of 86x109


/L and platelet count of 15x109 /L, without


flagging for urgent film review. This contributed to a delay in diagnosis of acute promyelocytic leukaemia (APML) for over 12 hours, and a delay in starting urgent chemotherapy. In addition to communication of the blood count results, there was a delay in the initial coagulation testing. A falling fibrinogen level of 1.2g/L on a subsequent day was not escalated as an urgent referral as it was above the local threshold for telephoning results. Cryoprecipitate was not administered for another 7.5 hours after the low fibrinogen result was available. Treatment was initiated urgently with blood component support, but the patient developed a subdural haemorrhage and died. There were multiple contributory factors, including untrained staff being allowed to work by themselves, and failures in communication from both the laboratory and clinical teams. This case description is significantly truncated, please refer for the Annual SHOT Report 2023 for the full case study.


had no formal arrangement for support outside of core working hours. Lone working may be considered a risk factor for transfusion errors, and laboratories may wish to evaluate when this is necessary, or other methods to alleviate pressures when a member of staff is working alone.


n Safety culture


A joint SHOT and UKTLC Laboratory Safety Culture Survey was undertaken in November 2023. The results were extremely concerning, but unfortunately to those working within transfusion laboratories, they were not unexpected. They demonstrated that laboratory staff


Digitisation, traceability


Clinical audit should include patient satisfaction and concern


Meeting needs for patients with sickle cell disease and thalassaemia


Safety as the main guiding principle


are still being a target of incivility and disciplinary action upon raising safety concerns or following incident reporting. Organisations must encourage a just culture and have a clear strategy to listen to staff, support them, and actively work to create safe work environments. In addition to enhancing staff wellbeing, this will ensuring the highest quality care for patients. Further detail can be found on the UKTLC webpage which is linked at the end of this article.


Laboratory key


recommendations n Patients should not die or suffer harm from avoidable delays in transfusion.


Adequate resources/funding support, safe staffing with appropriate training and knowledge


Safe transfusion decision-making, PBM practices, avoiding unnecessary transfusions, recording outcome of transfusions


Consent, shared decision-making, empowering the patient voice, getting answers when things go wrong; feedback loops in place


Laboratory safety


Transparency, duty of candour, leadership accountability, breaking silos


Safety culture, raising concerns, owning up when things go wrong


Reporting to SHOT and the MHRA; implementing safety


recommendations, report and act on NM, effective incident investigations which are fit for purpose


Fig 3. Key haemovigilance themes from the IBI report. WWW.PATHOLOGYINPRACTICE.COM FEBRUARY 2025 19


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