Transfusion hazards: going back to basics

The 15th Annual SHOT Report is compiled from data received between January and December 2011 by the SHOT UK national haemovigilance scheme. We are approaching universal participation, with 98.4% of National Health Service (NHS) hospitals, trusts and health boards across the UK now registered to report to SHOT, and registrations for independent organisations have also increased. The number of reports has increased to a total of 3,038 in 2011 (this total includes ‘near miss’ [n=1080] and ‘right blood right patient’ [n=159] events, which by definition caused no harm). This is an increase in analysed reports of 23.3% (3,038 vs 2,464) compared to the 2010 Annual Report. For the second consecutive year, there were no transfusion-transmitted infections. It is disappointing that half of all the events reported to SHOT in 2011 relate to errors in the basic transfusion process. The key lesson from 2011 is therefore ‘back to basics’. Figure 1 shows that many incidents are potentially preventable; particularly all adverse events due to errors, and also pathological reactions caused by transfusion-associated graft-versus-host disease (TA-GvHD), transfusion-related acute lung injury (TRALI) and transfusion-associated transfusion overload (TACO). In addition, some cases of haemolytic transfusion reaction (HTR) could be prevented if the diagnosis (e.g. sickle cell disease) and previous transfusion history (or presence of alloantibodies in the past) were more carefully obtained.

Back to basics

 ‘Back to basics’, the key lesson from 2011, is an emphasis again on the importance of the essential steps of the transfusion process: taking the blood sample from the correct patient, correct laboratory procedures, issuing the correct component, and finally identification of the right patient at the bedside at the time of transfusion. It is clear from the SHOT 2011 data that identification of the correct patient remains a key issue and that this must become a core clinical skill. The observation that mistakes are still made by individuals despite competence assessment has underlined the need to review education (to ensure a sound knowledge base) and competence, and communication failures arising between shifts or from shared care must be addressed by improved handover. About half of the cases reported to SHOT are due to preventable mistakes. Analysis of the ‘near miss’ data for the past two years indicates that for every ‘wrong blood in tube’ error that results in a ‘wrong blood’ incident, there are about 100 ‘near miss’ sample mistakes. Similarly, most of the serious adverse events reported to the Medicines and Healthcare products Regulatory Agency (MHRA) are also attributable to human error (788/811). For the first time this year, the SHOT report includes a chapter from the MHRA Serious Adverse Blood Reactions and Events (SABRE) reporting system (1,556 reports), and work has begun to see to what extent our two systems for haemovigilance can be harmonised.