Recommendations from the 2010 SHOT Report

Recommendations from the 2012 SHOT Report

For active recommendations from previous years and an update on their progress, please refer to the SHOT website

Recommendations from the 2012 SHOT Report v1.3 30.07.2013  Key Recommendations 2012

Action Recommendation Compliance

Hospital, Trust and Health Board Chief Executive Officers, Risk Patient identification: Correct and positive patient identification at every step remains Managers, absolutely essential, and is the responsibility of every member of staff. Hospitals/Trust Boards Pathology should review their identification procedures to ensure that patients are safely identified throughout their hospital journey. All UK patient safety programmes should take the Laboratory identification agenda forward as part of patient-centred care Managers and all staff involved in blood transfusion

Hospital Transfusion Team A zero-tolerance policy is recommended for the identification of all pathology specimens. In (HTT) Hospital other words, samples should not be accepted by the laboratory for analysis without the standard 4 Trust and Health identifiers used for transfusion samples, first name, surname, date of birth and an identity number, Board Pathology ideally the National Health Service (NHS) number. All pathology samples should be taken only after Managers, confirmation of identity, and be labelled at the patient’s side supported by Chief Executive Officers

All clinical and laboratory Communication and handover: Hospital and primary care staff should work at building staff in Hospitals, Trusts relationships to improve communication and handover. Communication failures within hospitals, and Health Boards, between hospitals and between hospital and primary care are all responsible for adverse incidents. General Practice and Good communication is required between laboratories and clinical staff and vice versa to ensure Community Hospitals specific requirements are met, and correct results communicated to clinical areas

Recommendations from the 2012 SHOT Report v1.3 30.07.2013 Chapter Recommendations 2012

Participation

Hospital Transfusion Teams working Different specialty areas have particular errors which should be addressed by attention to training and with specialties in communication – to reduce handling and storage errors in medicine and surgery, and to reduce the their number of cases where specific requirements are not met in haematology patients Hospitals/Health Boards

Hospital Transfusion Benchmarked participation data are both interesting and useful. Reporters should use this information Teams with support from to ensure their organisation is participating fully across all types of incident reporting i.e. errors, their Risk Managers and pathological reactions, anti-D and near miss events Chief Executive Officers

Anti-D Immunoglobulin

Hospital Reporters should inform the SHOT office when they find a case of a woman who has developed a new Transfusion immune anti-D that is detected during pregnancy, at delivery, or in a subsequent pregnancy, and a Teams (HTTs), questionnaire will be provided SHOT office

Hospital Transfusion reactions: all staff responsible for blood transfusion must know how to recognise Transfusion anaphylaxis and other acute transfusion reactions. Transfusions should only take place where there Teams, all are facilities to recognise and treat anaphylaxis and other adverse incidents, and local policies must clinicians involved ensure that procedures are in place to manage any adverse event or incident, including transfusions in in transfusion the community

Hospital Risk Managers; Hospital Transfusion Learn from adverse incidents: Incident reviews and root cause analyses should be completed and Recommendations from the 2012 SHOT Report v1.3 30.07.2013 the findings reported back to the participants and the patients to ensure that lessons are learned which Teams; all clinicians may reduce future errors

Recommendations from the 2012 SHOT Report v1.3 30.07.2013 Near Miss

Near miss reporting: Hospital staff should report ‘near miss’ as well as actual incidents in keeping Hospital Transfusion with good medical practice as defined by the General Medical Council (GMC) . Reporting is mandatory, Teams not voluntary, to ensure that the focus is improved patient safety

Hospital Laboratory and clinical areas should continue to report ‘near miss’ errors, as these are a useful Transfusion indication of potential failings, allowing corrective and preventative actions to be taken before any harm Committees (HTC) is done

Chief Executive Officers of Hospitals, There should be zero tolerance of sample labelling errors across all pathology disciplines and local Trusts/Health Boards, audits of sample labelling should continue to be undertaken to identify the ongoing risks of patient Pathology Laboratory misidentification Managers

Hospital There should be strict adherence to the requirement for a group check sample on patients without a Transfusion historical blood group as detailed in the British Committee for Standards in Haematology (BCSH) Committees (HTC) guidelines for pre-transfusion compatibility testing

Investigating Transfusion Incidents

Hospital All reported adverse incidents should be graded according to severity and risk of recurrence in order to Transfusion determine the level of appropriate investigation. Low risk incidents need not trigger a time-consuming Teams with process, but valuable lessons may be learned from review of these support from their Chief Executive Serious incidents require a full root cause analysis with feedback to all staff involved. The level of Officers. investigation must be governed by consideration for patient safety

Recommendations from the 2012 SHOT Report v1.3 30.07.2013 Incorrect Blood Component Transfused

Hospital Transfusion Teams, Royal College of It is essential that medical and nursing staff are educated to recognise and act on transfusion reactions Nursing, Royal College of as this might be the first sign of ABO incompatibility or anaphylaxis where prompt management may be Midwifery, General lifesaving Medical Council (for all medical curricula)

Hospital A recommendation from 2011 continues to be important. Every person in the transfusion process must Transfusion perform rigorous identity checks at each point and ensure that the component collected is the one Teams (HTT) prescribed. The use of a transfusion checklist is recommended

Transfusion Associated Circulatory Overload

The 2012 British Committee for Standards in Haematology (BCSH) addendum to the blood All clinicians administration guidelines on measures to reduce the risk of transfusion-associated circulatory overload (TACO) should be followed

Transfer of patients during a transfusion episode is potentially hazardous and should be avoided wherever possible. If unavoidable, clinical handover templates should include information on measures All clinicians to reduce the risk of TACO and appropriate monitoring in patients identified to be at risk by clinical assessment pre-transfusion

Post-transfusion clinical assessment should be also be undertaken and patients monitored for evidence of TACO during the first 24 hours after transfusion so that appropriate and timely management can be All clinicians instituted. Transfusions should only take place where there are facilities and trained staff to monitor and manage adverse incidents

Recommendations from the 2012 SHOT Report v1.3 30.07.2013 Paediatrics

Hospital Transfusion Hospital transfusion teams and clinical specialists should review local protocols and communication Teams, British pathways for emergency provision of blood for fetal and neonatal transfusion Maternal and Fetal Medicine Society

Hospital Transfusion Appropriate paediatric transfusion volumes and prescriptions should be the focus of ongoing education Teams, Accident in hospitals, particularly in situations of emergency transfusion, such as accident and emergency and Emergency departments Department Leads

Information Technology

In previous reports, it was identified that electronic access to the blood group and antibody information Hospitals supplied from reference laboratories by hospital transfusion laboratories would be helpful when managing the by NHSBT: transfusion support of complex patients, particularly if patients are treated in different hospitals and/or Hospital different geographical areas. This system is in the process of being implemented by the NHSBT and is Transfusion known as SP-ICE. The success of such a system in delivering safer patient care is dependent on a Teams, number of factors: Transfusion  That hospitals use common patient identifiers such as NHS number (or equivalent) when Laboratory sending samples to reference laboratories Managers with the  Those hospitals allow their patient data to be entered on the system, which is provided by an support of their NHS organisation and used by other NHS organisations to improve the safety of the Chief Executive transfusion support of individual patients Officers  That hospitals train all transfusion laboratory staff to use the system, including those providing an out-of-hours service

Recommendations from the 2012 SHOT Report v1.3 30.07.2013 Avoidable, Delayed or Undertransfusion

Hospital transfusion committees should review their transfusion protocols and training to ensure that all relevant departments in their hospitals, including radiology and any others where invasive procedures are performed, have appropriate measures in place Hospital Transfusion Transfusion laboratories should have protocols in place to ensure that fresh frozen plasma (FFP) is not Committees; used inappropriately for warfarin reversal. The correct treatment as recommended in British Committee Hospital for Standards in Haematology (BCSH) guidelines is to use PCC Transfusion Teams Biomedical scientific staff (BMS) and consultant haematologists need to educate users about the change in presentation of cryoprecipitate. BMS staff should be encouraged to challenge orders which seem inappropriate. Clinical staff should heed the advice of transfusion experts and check their request carefully

Trust/Hospital/Hea lth Board Chief A zero tolerance policy should be introduced for labelling of all patient samples and not restricted to Executive Officers transfusion samples. Dangerous consequences can arise from wrong full blood count, wrong (CEOs) Hospital coagulation and wrong biochemistry results. Pathology Particular attention should be paid to the correct labelling of all samples at the patient’s side, Managers; particularly in emergencies where additional delays resulting from a need for repeat samples may Hospital increase risks to the patient Transfusion Teams (HTT)

Recommendations from the 2012 SHOT Report v1.3 30.07.2013 Transfusion Laboratories

Transfusion Regular practice and competency-assessment of manual techniques is important, where possible this Laboratory should include checks of the critical steps by a second person when manual methods are employed Managers

Competency assessment in laboratories must be linked to process. Biomedical scientist (BMS) staff Transfusion must be competent performing the test but must also have a thorough understanding of the context in Laboratory which the test is being performed, i.e. the test in relation to a specific patient and the clinical Managers information. Basing competency assessment on National Occupational Standards (NOS) will enable this, as NOS have both ‘Performance’ criteria and ‘Knowledge and Understanding’ criteria

Transfusion Laboratory Managers, Hospital Transfusion Teams (HTTs) should perform a local risk assessment on the way in which the Pathology IT transfusion laboratory is informed by clinicians of either specific requirements, or previous history Managers, LIMS provided by patients direct to clinicians. For example, having a robust process to inform the laboratory providers, when treatment on purine analogues starts, rather than when blood is requested, has merit Hospital Transfusion teams (HTTs)

Transfusion Laboratory Managers, Warning flags must be clear and appear on all relevant screens in the transfusion process and if Pathology IT overridden, should include a positive response from the user with rational behind the decision Managers, LIMS providers, HTTs

Hospital Hospital transfusion laboratories should be encouraged to participate in the national electronic access Transfusion scheme for blood group and antibody information which is being developed by National Health Service Laboratory Blood & Transplant (NHSBT) (called Sp-ICE), and equivalent systems in Wales, Scotland and Northern Managers; Ireland for patients with complex transfusion requirements, and as recommended by National Patient Pathology Safety Agency (NPSA) safer practice notice, to use the NHS or number Managers

Recommendations from the 2012 SHOT Report v1.3 30.07.2013 Recommendations from the 2012 SHOT Report v1.3 30.07.2013 Acute Transfusion Reactions

Transfusions should only be performed where there are facilities to recognise and treat anaphylaxis, Hospital according to UK Resuscitation Council (UKRC) guidelines. This recommendation is also relevant for Transfusion other transfusion-related emergencies such as respiratory distress caused by transfusion-associated Teams (HTT), circulatory overload (TACO) or transfusion-related acute lung injury (TRALI). In supplying to General community hospitals or for home transfusions, providers must ensure that staff caring for patients Practitioners have the competency and facilities to deal with adverse incidents. This is particularly relevant in the light of proposed increase in treatment of patients outside the secondary care setting

In anaphylaxis, mast cell tryptase testing is not routinely required, but if needed because the clinical HTT diagnosis of anaphylaxis is in doubt, to be of value, serial mast cell tryptase levels are needed: a single result is of little diagnostic value

Mild acute transfusion reactions (ATRs) as defined by International Haemovigilance Network/International Society for Blood Transfusion (IHN/ISBT) (i.e. fever >38°C and a rise of 1-2°C HTT from pre-transfusion values, but no other symptoms; or transient flushing, urticaria or rash) should not be reported to SHOT

Haemolytic Transfusion Reactions

Hospital Hospital transfusion laboratories should ensure that an eluate is tested as part of the investigation of Transfusion a haemolytic transfusion reaction this may necessitate referring samples to a red cell reference Laboratory laboratory Managers

Recommendations from the 2012 SHOT Report v1.3 30.07.2013 Transfusion-Associated Graft versus Host Disease

Maternal blood should not be used for intrauterine transfusion (IUT) due to the risk of transfusion- British Maternal associated graft vs host disease (TA-GvHD). Fetal medicine units in conjunction with Hospital and Fetal Medicine Transfusion Teams should develop local written protocols with education regarding the appropriate Society, Hospital blood for emergency fetal transfusion. Whenever possible, irradiated red cells specific for IUT should Transfusion be used Teams with their In situations of immediate life-threatening emergency where there is not time to obtain specific IUT local Blood blood, alternatives include neonatal exchange units or paedipacks (likely to be non-irradiated in an Centres and emergency). The risk of TA-GvHD using these alternatives will be significantly lower, although not Consultant eliminated, than using maternal blood because these components have been leucodepleted and in Haematologists most cases there will be no shared haplotype between donor and recipient

The Blood Services should review their protocols for production of units for intrauterine transfusion (IUT), and establish the minimum time required to issue such units, even in an emergency. This UK Blood Services should be communicated to hospitals Requests for units for urgent intrauterine transfusion (IUT) should involve early direct discussion between a hospital clinician and a Blood Service consultant

BCSH Transfusion Update National irradiation guidelines via the British Committee for Standards in Haematology Task Force (BCSH)

Pulmonary Complications of Transfusion

Reporters are asked to provide as much of the information requested on the SHOT pulmonary Hospital questionnaire as possible. There is significant overlap between categories of pulmonary Transfusion complications and clinical detail is essential to allow accurate assessment of these cases Teams and Transfusions should only take place where there are facilities and staff trained to recognise and Reporters manage adverse incidents

Recommendations from the 2012 SHOT Report v1.3 30.07.2013 Transfusion Transmitted Infection

Clinicians, Retain suspected bacterially contaminated packs, even if near empty, for return to the Blood Service Transfusion and as the residue can be washed out and cultured. Report a suspected bacterial TTI promptly to the Microbiology Blood Service to allow recall of any associated packs for testing. If sampling packs locally for Laboratory bacterial testing, use ports rather than breaching the pack to minimise environmental contamination Managers of the pack

Clinicians, Transfusion Hospitals and Blood Centres investigating a possible viral TTI are reminded of the importance of Laboratory locating any archived recipient samples (transfusion-related or not) for testing. It is important that Managers, laboratories facilitate access to those samples (with due consent of appropriate parties including the Hospital patient) Transfusion Team (HTT)

Even if TTI is excluded in a case of ATR, the case should still be reported to SHOT as an ATR If HTTs, Clinicians necessary

Clinicians investigating suspected viral TTIs should explore all possible risk exposures in parallel with Clinicians, UK the Blood Service investigations, in order to determine the patient’s most likely source of infection. Blood Services This includes checking records and testing samples taken prior to the implicated transfusion(s) to check that the recipient was not infected prior to transfusion

Cell Salvage

Action Recommendation Compliance Hospital Transfusion All organisations should develop a robust system for reporting all adverse incidents/reactions during Committee, the use of autologous blood techniques, preferably reporting to the hospital transfusion committee Hospital and onward to SHOT Transfusion Teams

Recommendations from the 2012 SHOT Report v1.3 30.07.2013 Recommendations from the 2012 SHOT Report v1.3 30.07.2013 Transplant Cases

Clinical transplant To minimise transfusion errors, a written transplant programme detailing key dates and blood group teams; Transfusion information, should be developed for each transplant recipient. This should be sent, with written Laboratory confirmation of receipt, to the transfusion laboratory in the hospital where the transplant is being managers, Hospital undertaken, the shared care centre and its transfusion laboratory Transfusion Teams

The BCSH Transfusion Task Force; the British Guidelines should be developed that cover the procedures, particularly communication protocols, Society of Blood and necessary for managing transplant patients, especially where ABO/RhD mismatched transplants Marrow Transplantation have been given. This should be a standard for all transplant centres (BSBMT)

Unclassifiable Complications of Transfusion

Hospital Reactions and incidents after transfusion which do not fit into any of SHOT current reporting Transfusion categories may have important learning points and prompt others to report similar cases. Please Teams continue to discuss and submit such cases to SHOT

Recommendations from the 2012 SHOT Report v1.3 30.07.2013