Reducing adverse events in blood transfusion

Abstract

Summary Against a background of ever increasing expenditure on blood safety, less attention has been paid to improving the safety of the transfusion chain within hospitals. Based on reports to the Serious Hazards of Transfusion (SHOT scheme) between 1996 and 2003, the risk of an error occurring during transfusion of a blood component is estimated at 1:16 500, an ABO incompatible transfusion at 1:100 000 and the risk of death as a result of an ‘incorrect blood component transfused’ (IBCT) is around 1:1 500 000. There are opportunities for error at a number of critical points in the transfusion chain, starting with the decision to transfuse, prescription and request, patient sampling, pretransfusion testing and finally the collection of the component from the blood refrigerator and administration to the patient, consistently the commonest error in successive SHOT reports. Successive ‘Better Blood Transfusion’ initiatives and the 2003 Annual Report of the Chief Medical Officer for England have drawn welcome attention to the importance of safe and appropriate transfusion and the National Patient Safety Agency has now set a target of reducing the number of ABO incompatible transfusions by 50% over 3–5 years.

Screening of platelet concentrates for bacterial contamination: spectrum of bacteria detected, proportionof transfused units, and clinical follow-up

“…However, it is noteworthy that none of the six cases of mild clinical reactions in our study was reported actively but was revealed only by solicited feedback after the treating physicians had been questioned in the study follow-up by the blood service. This might indicate substantial underreporting of mild reactions in clinical practice and should remind the important part of transfusing physicians regarding to their responsibility in hemovigilance system [30]. In thrombocytopenic patients, in particular in hematooncology patients with concomitant neutropenia, bacterial contamination of blood products must be considered as one potential cause of febrile episodes.…”

Modifying the red cell surface: towards an ABO‐universal blood supply

“…ABOincompatible blood remains one of the leading causes of harmful or even fatal transfusion reactions reported to the national haemovigilance systems or governmental regulatory bodies, and human error accounts for most of these transfusion accidents. Following the successful implementation of screening tests for TTI markers and continuous improvement of test sensitivity and specificity, receiving the wrong RBC unit has become more likely than TTI (Sazama, 2003;Stainsby et al, 2005a;Stainsby et al, 2005bStainsby et al, , 2006 ( Fig 1). In the UK, this leads to an unacceptable and surprising number of ABO-incompatible transfusions every year (Fig 2) and haemovigilance systems in other countries show that this problem exists everywhere.…”

History and Hemolysis: Not an Easy Kidd’s Game and Review of Literature

“…HUS was the working diagnosis in the ED because of acute renal failure and hemolytic markers, but no evidence of thrombocytopenia and microangiopathic hemolytic anemia, which are classically observed in HUS (Razzaq, 2006), was observed in this patient. Our patient did have hemoglobinemia (Figure 1), but hemacommon foreign RBC antigens such as Rh, Kell, and Kidd (Stainsby et al, 2005). The eluate study in the appropriate clinical setting is diagnostic of DHTR (Engelfriet et al, 2006).…”