Serious Hazards Of Transfusion Scheme Research Articles

Hyperhemolysis in Patients With Hemoglobinopathies: A Single-Center Experience and Review of the Literature.

Hyperhemolysis is a severe and potentially life-threatening complication of transfusion described in numerous case reports and gaining recognition since 2009 via the UK Serious Hazards of Transfusion scheme. Although it is predominantly seen in patients with sickle cell disease, there are several reports of this complication in patients with other hemoglobinopathies as well as patients with a range of other hematologic diagnoses who have blood transfusions as part of their management. Our understanding of the underlying pathophysiology of this subtype of delayed transfusion reaction has increased over the last few years; however, there are still questions, which remain unanswered. In our center alone, we have encountered 9 cases in the last 5 years both in the adult and pediatric population. Here we discuss our experience in the diagnosis and management of this complication, and review other cases reported in the literature and the various existing theories behind the pathophysiology of this process. We also discuss the role of genotyping and using DNA technology to aid selection of the most appropriate blood for this patient group. With an increased awareness of hyperhemolysis, it would be advantageous to finally develop international registries to determine the true incidence of hyperhemolysis, better understand the pathophysiology, identify markers to predict which patients are at risk, and inform management guidelines.

The Example of the UK SHOT Haemovigilance System

SHOT (Serious Hazards of Transfusion scheme) is the UK’s National confidential haemovigilance system, and was set up in 1996. It is an independent, confidential, professionally led haemovigilance scheme. Initially the reporting was voluntary but now required by several professional bodies. SHOT publishes annual reports with recommendations and circulates to all relevant organizations including the 4 UK Blood services, Departments of Health in England, Wales, Scotland and Northern Ireland, all relevant professional bodies and reporting hospitals. Over the 17 years of reporting, the evidence gathered has prompted changes in transfusion practice from the selection and management of donors to changes in hospital practice, better education and training. Acute transfusion reactions and transfusion-associated circulatory overload carry the highest risk for morbidity and death. Greatest risk to patients remain errors in the process at the point of blood sampling, in the laboratory and at bedside administration. SHOT’s objectives are to use findings to improve standards of hospital transfusion practice, to educate users on transfusion hazards and prevention, to aid production of clinical guidelines in blood transfusion and to inform national policy on transfusion safety. MHRA is the UK competent authority to which serious adverse reactions and events have to be reported annually. Overall the most common adverse incidents are caused by errors, resulting in the transfusion of an incorrect component or one that does not meet the specific requirements of the patient (e.g. not irradiated or not appropriately antigen matched). TACO (transfusion associated circulatory overload) accounts for most deaths and major morbidity reported to SHOT but is overall underreported. Transfusions are not always given appropriately. This may be due to wrong haemoglobin results, failure to assess patients appropriately, or avoidable use of emergency O RhD negative units because of poor communication or planning. Review of cases of haemolytic transfusion reactions (HTR) shows that they are observed mainly in Sickle Cell Disease patients. HTR are associated with major morbidity (10/16 cases in sickle cell patients over 3 years) and death (a child in 2010). SCD patients are at particular risk of alloimmunization and this can be reduced by red cell phenotyping prior to the first transfusion followed by routine matching for at least the Rh and Kell groups. SHOT output data led over the time to the development of strategies to improve transfusion safety such as the implementation of guidelines for improving practice, implementation of the National Comparative Audit of Blood Transfusion programme, the publication of the Better blood transfusion initiatives and the establishment of The UK transfusion laboratory collaborative.

Ten years of hemovigilance reports of transfusion‐related acute lung injury in the United Kingdom and the impact of preferential use of male donor plasma

From 1996 through 2006, 195 cases were reported as transfusion-related acute lung injury (TRALI) to the Serious Hazards of Transfusion scheme and from 1999 onward classified by probability, using clinical features and HLA and/or HNA typing. From late 2003, the National Blood Service provided 80 to 90 percent of fresh-frozen plasma (FFP) and plasma for platelet (PLT) pools from male donors. Forty-nine percent of reports were highly likely/probable TRALI, and 51 percent possible/unlikely. Of 96 investigations, donor antibodies recognizing recipient antigens were found in 73 cases (65%), with HLA Class I in 25 of those (40%), HLA Class II antibodies in 38 (62%), and granulocyte antibodies in 12 (17%). A review in 2003 revealed that the TRALI risk/component was 6.9 times higher for FFP and 8.2 times higher for PLTs than for red blood cells, and that in donors of implicated FFP/PLTs, white blood cell antibodies were found 3.6 times more often than by chance (p <or= 0.0001), with all implicated donors being female. Provision of male plasma was associated with a reduction in TRALI reports from 36 in 2003 to 23 in each of 2004 and 2005 and 10 in 2006. Highly likely/probable cases reduced from 22 in 2003 to 13, 6, and 3 [corrected] in the 3 subsequent years, with cases implicating FFP or PLTs with positive donor serology [corrected] falling from 16 to 9, 3, and 1 respectively. The risk of highly likely/probable TRALI due to FFP has fallen from 15.5 per million units issued during 1999 through 2004 to 3.2 per million during 2005 through 2006 (p = 0.0079) and from 14.0 per million to 5.8 per million for PLTs.

Adverse outcomes of blood transfusion in children: analysis of UK reports to the serious hazards of transfusion scheme 1996–2005

Between 1996 and 2005 the Serious Hazards of Transfusion (SHOT) scheme analysed 3239 reports of adverse reactions and events associated with transfusion of labile blood components in the UK. 321 reports (10%) related to transfusion of children under 18 years and 147/3239 (4.5%) to infants less than 12 months of age. There were 264 cases in children of 'incorrect blood component transfused', resulting from errors at all stages in the transfusion chain; 26/264 suffered actual or potential morbidity. Thirty acute transfusion reactions, three delayed transfusion reactions, 20 cases (three fatal) of transfusion-related acute lung injury, two cases (both fatal) of transfusion-associated graft-versus-host disease and two transfusion transmitted infections were reported. A population-based epidemiological study of transfused patients in 2004 showed that 4.2% of red cells are transfused to patients less than 18 years and 1.7% to infants less than 12 months. Interpretation of SHOT data against this context enabled the estimation of the incidence of an adverse outcome to be 18:100,000 red cells issued for children less than 18 years and 37:100,000 for infants less than 12 months, compared to 13:100,000 for adults. Adherence to relevant guidelines, knowledge of specialist transfusion needs of children and good communication are essential if this risk is to be reduced.

Performance and practice in UK hospital transfusion laboratories

The two main sources of data for assessment of performance and practice are external quality assessment (EQA) and haemovigilance. In the UK both have their limitations, but are broadly representative of UK-wide clinical practice. Data from the Serious Hazards of Transfusion scheme (SHOT), show that approximately 30% of errors occur in the laboratory. ABO grouping errors are of particular concern, and were the cause of one death and one case of serious morbidity during 2004. Laboratory practice is changing, with an increase in the use of column agglutination technology (CAT) and automation, and a consequent increase in abbreviated testing. Transcription and transposition errors are a continual problem, particularly in manual systems and are responsible for many reports to SHOT as well as in EQA. Reagent selection and result interpretation play a major part in D typing errors seen in UK NEQAS exercises, with anti-CDE and potentiated anti-D reagents responsible for mistyping of rr cells. EQA results show some lack of understanding and knowledge with respect to antibody identification, with errors occurring due to inappropriate pattern matching, with no consideration given to masked antibodies. UK NEQAS data show that performance has improved enormously over the decades, but errors are still occurring in all parts of the process.

Evaluation of a teaching pack designed for nursing students to acquire the essential knowledge for competent practice in blood transfusion administration

This article describes the evaluation of a teaching pack designed for nursing students to acquire the knowledge required for safe administration of blood transfusions. The Serious Hazards of Transfusion (SHOT) Committee is a confidential reporting body, which gathers data from the United Kingdom and reports the serious sequelae of blood transfusion. The SHOT reports have repeatedly identified that errors in blood transfusions are wholly avoidable. Nurses, as the health care professionals ultimately responsible for the bedside check, have the final opportunity to prevent a mis-transfusion [Nursing and Midwifery Council, 2004a. The NMC code of professional conduct: standards for conduct, performance and ethics. NMC, London; Serious Hazards of Transfusion, 2002. SHOT Annual Report 2001-2002. SHOT Scheme, Manchester]. The educational strategies implemented will be explained and evidence that applying structured learning programmes in the undergraduate nursing curriculum can improve students' knowledge presented. A structured questionnaire was employed to assess students' knowledge of the process for transfusing blood components pre- and post-teaching and evaluate the effectiveness of the teaching pack. The results will be presented and discussed.

P17 Bedside Practice of Blood Transfusion ‐ Where is the Evidence?

Background There have been no systematic reviews of the routine ‘bedside practice’ of blood transfusion. There are national guidelines, but local practice varies. Nursing staff are increasingly requesting details of the evidence that underpins the guidelines. Transfusion practitioners from the four UK blood transfusion services working with the NBS Systematic Review Initiative have systematically reviewed the evidence for practice in four key areas of bedside blood transfusion.Methods Relevant evidence was identified through comprehensive searches of electronic databases: Medline; Embase; Cinahl; The Cochrane Library; websites of international blood transfusion societies and the websites of the US Centres for Disease Control and Prevention, English National Patients Safety Agency and the NHS Serious Hazards of Transfusion Scheme. Reference lists of relevant papers were scanned and contact was made with transfusion medicine clinicians and scientists to identify additional evidence. All identified papers were assessed for project eligibility: eligible papers were quality assessed and data extracted by two members of the project team, working independently of each other.Results The searches yielded approx. 6000 hits. Relevant evidence was identified for one area: co‐administration of drugs with blood (approx. 50 papers). Indirectly relevant evidence was identified for the maximum time that a unit of blood can be safely left out of refridgeration (approx. six papers). No relevant published information was identified for the frequency of change of blood administration or for the relative safety of 1 versus 2 person checking blood prior to infusion.Conclusions For three of the four areas despite minimal restrictions on study design there was little relevant published evidence to underpin practice. Where evidence does exist, it is not necessarily directly related to bedside blood transfusion practice or is ‘out‐of‐date’. The principal recommendation from this project is the need to undertake directly relevant primary research, including assessing the bacterial contamination of blood during the transfusion process and a national randomised controlled trial of the safety of 1 versus 2 person checking.

Rubella dilemma: are patients being immunised unnecessarily?

The two main sources of data for assessment of performance and practice are external quality assessment (EQA) and haemovigilance. In the UK both have their limitations, but are broadly representative of UK-wide clinical practice. Data from the Serious Hazards of Transfusion scheme (SHOT), show that approximately 30% of errors occur in the laboratory. ABO grouping errors are of particular concern, and were the cause of one death and one case of serious morbidity during 2004. Laboratory practice is changing, with an increase in the use of column agglutination technology (CAT) and automation, and a consequent increase in abbreviated testing. Transcription and transposition errors are a continual problem, particularly in manual systems and are responsible for many reports to SHOT as well as in EQA. Reagent selection and result interpretation play a major part in D typing errors seen in UK NEQAS exercises, with anti-CDE and potentiated anti-D reagents responsible for mistyping of rr cells. EQA results show some lack of understanding and knowledge with respect to antibody identification, with errors occurring due to inappropriate pattern matching, with no consideration given to masked antibodies. UK NEQAS data show that performance has improved enormously over the decades, but errors are still occurring in all parts of the process.

Providing feedback to users on unacceptable practice in the delivery of a hospital transfusion service--a pilot study.

The Serious Hazards of Transfusion Scheme's (SHOT) annual report continues to emphasize the importance of investigating serious transfusion errors. It is now recognized that lessons can also be learnt from near-miss events as these occur more frequently than serious errors in transfusion. One of the key features in developing a culture that can promote safety in relation to transfusion is providing feedback to staff on what is acceptable and unacceptable practice. We have developed a scoring system based on the number of serious errors and near misses that occur in the transfusion service to provide feedback to staff on their performance in relation to the administration of blood components and blood products. This was developed as part of an ongoing error logging system that we have previously described. The implementation of this feedback has resulted in an increased awareness within our organization of safety issues in relation to transfusion, and has highlighted the importance of the detection and correction of less serious errors.