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Serious Hazards of Transfusion (SHOT) Annual Report 2017

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ANNUAL SHOT REPORT 2017 working with Affiliated to the Royal College of Pathologists DS OF ZAR TR A AN H S S F U U O S I I R O E N S A Y N R N A U S A R L E S YEARS IV H N O N T A RE T PORT 21S ANNUAL SHOT REPORT 2017 Serious Hazards of Transfusion (SHOT) Steering Group Chair Professor Mark Bellamy SHOT Medical Director Dr Paula Bolton-Maggs Operations Manager Ms Alison Watt Research Analyst Ms Debbi Poles Patient Blood Management Practitioner Mrs Jayne Addison Clinical Incidents Specialist Mr Simon Carter-Graham Mrs Ann Fogg Laboratory Incidents Specialist Mrs Hema Mistry National Coordinator for Mrs Rachael Morrison (Ms Dory Kovacs in 2018) Transfusion-Transmitted Infections (Public Health England) Working Expert Group (WEG) & Writing Group, on behalf of the SHOT Steering Group Chair: Dr Paula Bolton-Maggs Professor Mark Bellamy, Ms Alison Watt, Ms Debbi Poles, Mrs Hema Mistry, Mr Simon Carter-Graham, Mrs Ann Fogg, Mrs Jayne Addison, Mrs Rachael Morrison, Dr Tom Latham, Mrs Diane Sydney, Dr Helen New, Dr Megan Rowley, Dr Fiona Regan, Mr Chris Robbie, Dr Peter Baker, Dr Janet Birchall, Dr Jane Keidan, Mrs Terrie Perry, Mrs Katy Cowan, Dr Sharran Grey, Mrs Clare Denison, Dr Catherine Ralph, Dr Sarah Haynes, Mrs Pamela Diamond, Dr Anicee Danaee, Ms Tracey Tomlinson, Dr Shruthi Narayan, Mrs Heather Clarke. Steering Group (SG) during 2017 Chair: Professor Mark Bellamy Dr Shubha Allard British Society for Haematology Guidelines National Blood Transfusion Committee Dr Ganesh Suntharalingam Intensive Care Society, Faculty of Intensive Care Medicine Dr Su Brailsford Public Health England & Faculty of Public Health Mrs Rashmi Rook UK Transfusion Laboratory Collaborative Dr Ruth Gottstein Royal College of Paediatrics and Child Health Major Jeremy Grindrod Defence Medical Services Dr Ranga Mothukuri College of Emergency Medicine Dr Patricia Hewitt Consultant Specialist in Transfusion Microbiology, NHSBT Ms Rose Gallagher/Anna Crossley Royal College of Nursing Ms Mervi Jokinen Royal College of Midwives Ms Jenny Berryman Institute of Biomedical Science Mr Chris Robbie Medicines and Healthcare Products Regulatory Agency Dr Sheila MacLennan Joint Professional Advisory Committee Dr Gail Miflin UK Forum Mr William Chaffe British Blood Transfusion Society Dr Megan Rowley Royal College of Pathologists (also member of WEG) Dr Kieran Morris Northern Ireland Regional Transfusion Committee Dr Krishna Ramachandran Royal College of Anaesthetists Dr Charles Percy British Society for Haematology Dr Edward Norris-Cervetto Trainee Representative for British Blood Transfusion Society Dr Anne Morrison Scottish Clinical Transfusion Advisory Committee Dr Rosie Hamilton Royal College of Obstetricians and Gynaecologists Dr Andrew Thillainayagam British Society of Gastroenterology and Royal College of Physicians Dr James Reid Royal College of Physicians Mr John Thompson Royal College of Surgeons Mr Toby Richards Royal College of Surgeons Ms Nina Vinall Expertise in Patient Safety Mr Graham Donald Lay member Honorary Steering Group Members Professor Hannah Cohen Founder Member and former Steering Group Chair Dr Dafydd Thomas Former Steering Group Chair Dr Lorna Williamson Founder Member Dr John Barbara Founder Member Prof John Lumley Founder Member Dr Brian McClelland Founder Member Dr Derek Norfolk Founder Member Dr Clare Taylor Former SHOT Medical Director Dr Sue Knowles Former Interim Medical Director of SHOT Dr Dorothy Stainsby Former National Medical Coordinator of SHOT Dr Elizabeth Love Former National Medical Coordinator of SHOT NB. All members of the WEG are members of the Steering Group in their own right. ANNUAL SHOT REPORT 2017 Requests for further information should be addressed to: Non-infectious hazards Infectious hazards SHOT Office Dory Kovacs Manchester Blood Centre Scientist (Epidemiology) Plymouth Grove Public Health England Epidemiology Unit /NHSBT Manchester 61 Colindale Avenue M13 9LL London NW9 5EQ Tel +44 (0) 161 423 4208 Tel +44 (0)20 8327 7602 Website www.shotuk.org Email [email protected] Twitter @shothv1 Enquiries [email protected] Email [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] Copyright notice Please cite this work as: PHB Bolton-Maggs (Ed) D Poles et al. on behalf of the Serious Hazards of Transfusion (SHOT) Steering Group. The 2017 Annual SHOT Report (2018). This work was undertaken by SHOT. The work was funded by NHS Blood and Transplant, Northern Ireland Blood Transfusion Service, Scottish National Blood Transfusion Service and the Welsh Blood Service through the UK Forum. This report and the individual contributions within it are protected by copyright. The report may be circulated and used for internal, non-commercial purposes within an organisation or institution. Derivative works: Permission from SHOT is required for all derivative works including adaptations and translations. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of SHOT, or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK (www.cla.co.uk). Enquiries concerning reproduction outside the terms stated here should be sent to SHOT at the address printed on this page. Making duplicate copies of this Report, or use of the data within, for legitimate clinical, scientific, educational or other non-commercial purposes (not including derivative data) is permitted provided that SHOT is identified as the originator of the information. Electronic Storage or Usage: Permission from SHOT is required to store or use electronically any material contained in this publication, including any part of a chapter. Making alterations to any of the information contained within, or using the information in any other work or publication without prior permission, will be a direct breach of copyright. The use of registered names, trademarks etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulation and therefore free for general use. Copyright © Serious Hazards of Transfusion (SHOT) 2018 Published July 2018 ISBN 978-1-9995968-0-4 Contents Page Chapter 5 1 Foreword ........................................................................................................................Mark Bellamy 7 2 Participation in UK Haemovigilance ........................Debbi Poles, Chris Robbie and Paula Bolton-Maggs 10 3 Headline Data: Deaths, Major Morbidity and ABO-Incompatible Transfusions ......... Paula Bolton-Maggs 17 4 Key Messages and Recommendations ...................................... Paula Bolton-Maggs and Mark Bellamy 20 5 Donor Haemovigilance .................................................................................................. Shruthi Narayan 27 ERROR REPORTS: Human Factors 28 6 Human Factors in SHOT Error Incidents ........................................Alison Watt and Paula Bolton-Maggs 34 7 Laboratory Errors ............................................................ Peter Baker, Heather Clarke and Hema Mistry 51 8 Right Blood Right Patient (RBRP) .......................................................... Diane Sydney and Hema Mistry 55 9 Handling and Storage Errors (HSE) ........................................................ Diane Sydney and Hema Mistry 58 10 Incorrect Blood Component Transfused (IBCT) ....................................................................................... .............................Jayne Addison, Peter Baker, Heather Clarke, Hema Mistry and Paula Bolton-Maggs 81 11 Avoidable, Delayed or Under or Overtransfusion (ADU) ............... Paula Bolton-Maggs and Caroline Wall 82 a. Delayed Transfusions 90 b. Avoidable Transfusions 95 c. Under or Overtransfusion 97 d. Incidents related to Prothrombin Complex Concentrates 99 12 Near Miss Reporting (NM) .........................................................................Alison Watt and Katy Cowan 104 13 Errors Related to Information Technology (IT) ..................................................................Megan Rowley 106 14 Adverse Events Related to Anti-D Immunoglobulin (Ig) .......................... Clare Denison and Katy Cowan 114 15 Immune Anti-D in Pregnancy: Cases reported up to the end of 2017 .................................Jane Keidan 127 REACTIONS IN PATIENTS Serious Adverse Reactions including EU definition 128 16 Febrile, Allergic and Hypotensive Reactions (FAHR) ...............................Janet Birchall and Fiona Regan 134 17 Transfusion-Transmitted Infections (TTI) .......................................... Rachael Morrison and Su Brailsford 142 18 Pulmonary Complications 144 a. Transfusion-Related Acute Lung Injury (TRALI) ............................................................. Tom Latham 148 b. Transfusion-Associated Circulatory Overload (TACO) ...........Sharran Grey and Paula Bolton-Maggs 154 c. Transfusion-Associated Dyspnoea (TAD) .......................................................... Paula Bolton-Maggs 158 19 Haemolytic Transfusion Reactions (HTR) ......................................Tracey Tomlinson and Anicee Danaee 165 20 New or Unclassifiable Complications of Transfusion (UCT) ..................................... Paula Bolton-Maggs 166 21 Cell Salvage (CS) .............................................................................Sarah
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