Health Service Focus

A SHOT at better blood transfusion

Around half of all blood transfusion incidents reported are avoidable. Kate Ashley looks into the most recent SHOT report, which gathers this data and applies it to improve practice.

While death rates due to blood transfusion complications and errors are rare and getting rarer, ‘near miss’ events still happen with alarming frequency, leading to hundreds of preventable incidents each year.

Taking the time to conduct transfusion procedures correctly in the midst of staff shortages and rising pressure is undoubtedly difficult. Yet further training and guidance must be implemented to ensure the multiple ‘near miss’ events do not turn into real hazards.

The Serious Hazards of Transfusion (SHOT) annual report, published July 6, reviewed data received between January and December 2011 by the SHOT  national haemoviligance scheme and concluded that the NHS must go ‘back to basics’ on blood transfusion.

For the first time, the report also included a contribution from the Serious Adverse Blood Reactions and Events (SABRE) data and its analysis compiled by the Medicines and Healthcare products Regulatory Agency (MHRA) as one of the ongoing steps towards harmonisation of the two systems into a single UK haemovigilance scheme. In the short term, the organisations aim to have a single entry portal for reports, with meetings in the future to compare mortality and major morbidity data.

Preventable incidents

In 2011, there were no cases of transfusiontransmitted infections (TTI) and the health service maintained the downwards trend in transfusion-related acute lung injury, but there were still significant problems regarding human error and ‘near-misses’. The number of deaths where transfusion played a role was eight in 2011, down from 13 in 2010. In two of these cases, the level of imputability was certain. In the other six it was possible. However, the rate of major morbidity was up from 101 in 2010 to 117 in 2011. Acute Transfusion Reactions (ATR) was the leading cause of major morbidity in 2011 and there was also a high level of Transfusion Associated Circulatory Overload (TACO) – an important cause of potentially avoidable major morbidity and death.

Cases of TACO should be avoidable, the report stated, through pre-transfusion assessment, an appropriate rate of transfusion and fluid balance monitoring.

The proportion of death and major morbidity in 2011 was 6.9% per three million components transfused across the UK each year. About half of all the reports are of adverse events caused by errors, which should all be preventable. SHOT UK is advocating more education and training for all clinicians to aid improvements in this area.

Human error

The report emphasised the importance of the basic steps in the transfusion process: correct patient identification at the time of blood sampling, correct laboratory procedures, collection of the right product and the importance of checking the identity of the patient at the bedside.

It notes: “It is dangerous to make assumptions.”

Each year the number of reports of ‘near miss’ events is around a third of the total, and was 1,080 in 2011. Half of these are sample errors such as ‘wrong blood in the tube’ or handling and storage errors; all are related to mistakes.

This human error can be related to poor systems: but also distraction, interruption and rushing or cutting corners, related to urgency or a lack of staffing, the MHRA suggested.

The report said: “We must all work together to reduce this, which means continued examination of our hospital transfusion processes.”

Education and identification

Patient identification remains “a key issue”, the report stated and should be a core clinical skill; something SHOT UK has presented to the GMC for consideration.

Additionally, education and training on blood transfusion is “still not sufficiently effective” and needs to be underpinned by a better knowledge and understanding of transfusion medicine in clinical work, as part of the core curriculum for all clinicians.

SHOT UK highlighted the continued level of errors resulting in wrong transfusions, inappropriate, unnecessary and under/delayed transfusions, poor handling of components and the high proportion of ‘near miss’ reporting as “disappointing”, due to repeated efforts to improve transfusion safety through a variety of national schemes.

The report adds: “It is clear that the ability to pass competency assessments does not necessarily result in correct and safe transfusion practice.” The NHS must ensure it is safe in practice, not just on paper.

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