TRANSFUSION SCIENCE
Where transfusion needs are complex, laboratory staff should have access to and follow specialist advice to provide the most suitable component available. Hospital policies and processes must reflect this.
n Staff must have protected time for training and education to provide a safe service.
n Bespoke operational roles should be considered for project/change implementation to ease the pressure on routine staff.
n Policies for lone working should be reviewed to identify when extra support or reallocation of tasks are required.
n A just and learning safety culture is vital to support the safety of patients and staff members, and not worsen existing recruitment and retention pressures in the laboratory.
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Acknowledging continuing excellence (ACE) Despite numerous challenges related to workload, training and culture, laboratory staff are working tirelessly to provide support to patients. There were four ACE cases reported in 2023 which illustrate excellent communication, collaboration and focus on patient safety by transfusion laboratory staff. One such case is detailed in this article as case study 3.
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It is evident that many errors reported in the Annual SHOT Report 2023 were potentially preventable and may not have occurred in periods of proper staffing and resource allocation. There has been a reduction in staffing availability, change in education of newly qualified staff with de-prioritisation for transfusion, and increased workload alongside
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Sample receipt and reigistration
Testing Component selection Component labelling Availability Handling and stoarge Miscellaneous 3
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RBRP
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IBCT-WCT: Incorrect blood component transfused - wrong component transfused; IBCT-SRNM: IBCT-specific requirements not met; HSE: Handling and storage errors; RBRP: Right blood right patient; PCC: Prothrombin complex concentrate; lg: immunoglobulin. Note: numbers <3 are too small to be annotated on the figure.
Fig 4. SHOT laboratory errors 2023 classified by outcome and step in the process where the primary error occurred.
many necessary improvement projects. Transfusion laboratory professionals need to be appropriately supported so they may continue to provide high-quality patient-centred services. It is essential that staff members can acknowledge and escalate when patient and professional safety concerns arise.
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who work under immensely stressful situations to save and improve lives.
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Further resources n For a more detailed analysis please visit
The findings of the IBI were truly tragic. There is hope that having a light shone upon such vast failings can initiate thorough widespread systemic changes and highlight the importance of an open and honest culture. As a healthcare community, we must harness and learn from these findings to help improve safety for patients yet to come.
SHOT would like to acknowledge the unwavering commitment, dedication, and tireless efforts by all staff in transfusion,
Case study 3 Wrong blood in tube (WBIT) identified through biomedical scientist initiative
Patient 1 required an urgent red cell transfusion in the emergency department (ED). Two group and screen (G&S) samples were taken from patient 1 but labelled with patient 2’s details. When clinical staff contacted the transfusion laboratory to query receipt of the samples and availability of blood, the laboratory confirmed no samples from patient 1 had been received. After centrifuging the G&S samples labelled for patient 2, the biomedical scientist identified visually that the haematocrit was very low and decided to check the result against a recent FBC for patient 2. Haematocrit results were discrepant, and the BMS was able to confirm with the ED that a WBIT event had occurred.
The biomedical scientist was praised for their outstanding vigilance and importance of maintaining a wide view of laboratory processes. Following this, several improvement measures were implemented including drop-in sessions for sample taking, involvement from the quality teams to implement changes and communication at a trust-wide level.
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the SHOT website to download the full 2023 Annual SHOT Report and Summary, and Gap Analysis Tool for implementation of recommendations -
www.shotuk. org/shot-reports/report-summary-and- supplement-2023/. Or download the free SHOT App (search SHOT UK in app and play stores).
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n Infected blood inquiry (2024) www.
infectedbloodinquiry.org.uk/reports/inquiry- report
n Abbreviated UKTLC standards, UKTLC survey 2022 and SHOT and UKTLC culture survey 2023 -
https://www.shotuk.org/ resources/current-resources/uktlc/
SHOT
Manchester Blood Centre, Plymouth Grove, Manchester, M13 9LL
+44 (0) 161 423 4208
shot@nhsbt.nhs.uk www.shotuk.org @SHOTHV1
The case studies included are from the Annual SHOT Reports and the details are as provided to SHOT by reporters. All the published Annual SHOT Reports can be accessed at
www.shotuk.org. The cases are shared only to promote the learning from the incidents reported and improve transfusion safety. The SHOT team acknowledge and appreciate the valuable contributions of haemovigilance reporters across the UK and members of the SHOT Steering Group and Working Expert Group.
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