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Cases from the 2008 SHOT Report
Cases from the 2008 SHOT Report
Poor decision making / lack of understanding Slide 4 Failure of
Poor decision making / lack of understanding Slide 4 Failure of
Poor decision making / lack of understanding
Poor decision making / lack of understanding
Lack of recognition of paediatric emergency units A neonate required
Lack of recognition of paediatric emergency units A neonate required
Red cells administered instead of platelets A unit of platelets was
Red cells administered instead of platelets A unit of platelets was
FFP administered instead of platelets Red cells, platelets and FFP
FFP administered instead of platelets Red cells, platelets and FFP
FFP administered instead of platelets FFP, red cells and platelets
FFP administered instead of platelets FFP, red cells and platelets
Platelets administered without a prescription Platelets had been
Platelets administered without a prescription Platelets had been
Lack of communication between shifts in SCBU results in baby being
Lack of communication between shifts in SCBU results in baby being
Inadequate management of acute bleeding associated with high INR on
Inadequate management of acute bleeding associated with high INR on
Over-estimation of blood loss from GI bleeding leads to massive
Over-estimation of blood loss from GI bleeding leads to massive
Overestimation of blood loss from acute GI bleed A patient was
Overestimation of blood loss from acute GI bleed A patient was
Overtransfusion and subsequent venesection of a 1-year old under
Overtransfusion and subsequent venesection of a 1-year old under
Confusion over correct dosage of cryoprecipitate A patient was
Confusion over correct dosage of cryoprecipitate A patient was
Failure of checking procedures
Failure of checking procedures
Lack of understanding of what a bedside check involves, and why A
Lack of understanding of what a bedside check involves, and why A
No patient ID check when administering group-specific units A 77-year
No patient ID check when administering group-specific units A 77-year
Acute haemolytic reaction in a frail elderly man administered
Acute haemolytic reaction in a frail elderly man administered
Lack of positive ID check at collection and administration A 92-year
Lack of positive ID check at collection and administration A 92-year
Lack of ID checks at patients side A haematology patient required a
Lack of ID checks at patients side A haematology patient required a
No patient ID check made in emergency situation when box of blood for
No patient ID check made in emergency situation when box of blood for
Bedside check omitted in favour of a treatment room check Forms and
Bedside check omitted in favour of a treatment room check Forms and
Sampling / Results errors
Sampling / Results errors
Doctors phlebotomy error results in 2 unit ABO-incompatible
Doctors phlebotomy error results in 2 unit ABO-incompatible
Phlebotomists patient ID error results in 3 unit ABO-incompatible
Phlebotomists patient ID error results in 3 unit ABO-incompatible
Acute HTR from ABO-incompatible transfusion comes to light 11 years
Acute HTR from ABO-incompatible transfusion comes to light 11 years
Doctors phlebotomy error in emergency situation A middle-aged man
Doctors phlebotomy error in emergency situation A middle-aged man
Incorrect Hb level and group following patient ID error A middle-aged
Incorrect Hb level and group following patient ID error A middle-aged
Transfusion and multiple investigations based on a drip arm
Transfusion and multiple investigations based on a drip arm
Transfusion based on a year-old haemoglobin result Two units of blood
Transfusion based on a year-old haemoglobin result Two units of blood
Spurious pancytopenia results in unnecessary hospital admission and
Spurious pancytopenia results in unnecessary hospital admission and
Short sample gives spurious result leading to 3-unit transfusion A
Short sample gives spurious result leading to 3-unit transfusion A
Unnecessary transfusion based on obviously erroneous result A patient
Unnecessary transfusion based on obviously erroneous result A patient
Handling / storage errors
Handling / storage errors
Transfusion continued despite leak from port exposing contents to
Transfusion continued despite leak from port exposing contents to
Lack of knowledge leads to inappropriate concerns and non-compliance
Lack of knowledge leads to inappropriate concerns and non-compliance
In absence of security normally provided by an electronic system,
In absence of security normally provided by an electronic system,
Slow transfusion due to poor venous access not attended to
Slow transfusion due to poor venous access not attended to
Overnight transfusion prescribed for 4 hours not monitored and runs
Overnight transfusion prescribed for 4 hours not monitored and runs
Undue responsibility placed with porter, and lack of liaison about
Undue responsibility placed with porter, and lack of liaison about
Red cell unit returned to stock despite being out of controlled
Red cell unit returned to stock despite being out of controlled
Undue responsibility placed with porter, compounded by ignoring the
Undue responsibility placed with porter, compounded by ignoring the
Problems with collection
Problems with collection
Incorrect documentation used to collect red cells from issue
Incorrect documentation used to collect red cells from issue
Incorrect units collected in place of emergency group O RhD negative
Incorrect units collected in place of emergency group O RhD negative
Problems with patient ID
Problems with patient ID
One patient  two wristbands A 69-year old male patient was in ITU
One patient two wristbands A 69-year old male patient was in ITU
Dual registration results in misgrouping of a massively transfused
Dual registration results in misgrouping of a massively transfused
Wrongly labelled unit transfused despite original error having been
Wrongly labelled unit transfused despite original error having been
A pointless check between two incorrect documents generated by the
A pointless check between two incorrect documents generated by the
Laboratory errors
Laboratory errors
Electronic records and automation highlight historical error At
Electronic records and automation highlight historical error At
When IT fails, electronic issue cannot be used A 19-year old female
When IT fails, electronic issue cannot be used A 19-year old female
Competency assessment on blood group anomalies must form part of
Competency assessment on blood group anomalies must form part of
The difficulties encountered with cases of AIHA A 93-year old female
The difficulties encountered with cases of AIHA A 93-year old female
RhD types must not be assigned on one weak reaction A patient
RhD types must not be assigned on one weak reaction A patient
Take due care when selecting blood for special patient groups Two
Take due care when selecting blood for special patient groups Two
Take due care when selecting platelets for special cases NHSBT
Take due care when selecting platelets for special cases NHSBT
Is causing less distress to a paediatric patient a valid reason for
Is causing less distress to a paediatric patient a valid reason for
IT warning flags are only helpful prompts  staff must understand the
IT warning flags are only helpful prompts staff must understand the
The importance of antibody history A patient arrived in the ED with a
The importance of antibody history A patient arrived in the ED with a
The need for complete documentation Six units of blood were issued
The need for complete documentation Six units of blood were issued
The danger of manual transcription of results when the computer is
The danger of manual transcription of results when the computer is
Multiple errors lead to transfusion of red cells of the wrong ABO
Multiple errors lead to transfusion of red cells of the wrong ABO
Cryoprecipitate mistakenly issued instead of FFP An urgent request for
Cryoprecipitate mistakenly issued instead of FFP An urgent request for
Computer rule leads to transfusion of non-irradiated and CMV-screened
Computer rule leads to transfusion of non-irradiated and CMV-screened
Failure to follow guidelines
Failure to follow guidelines
A hydropic baby is transfused S-positive units, though mother had
A hydropic baby is transfused S-positive units, though mother had
Special requirements
Special requirements
Requestor does not inform the transfusion laboratory that patient is
Requestor does not inform the transfusion laboratory that patient is
Sickle cell disease not stated on request for red cells A patient
Sickle cell disease not stated on request for red cells A patient
Transplant centre did not inform referring hospital of ABO-mismatched
Transplant centre did not inform referring hospital of ABO-mismatched
Laboratory misses fact that there are TWO special requirements A
Laboratory misses fact that there are TWO special requirements A
BMS omits to issue CMV negative components for pregnant woman with
BMS omits to issue CMV negative components for pregnant woman with
Anti-D
Anti-D
Manual transcription error in the laboratory results in omission of
Manual transcription error in the laboratory results in omission of
Weak D baby recorded as D negative A BMS altered a babys blood
Weak D baby recorded as D negative A BMS altered a babys blood
Lack of knowledge of when it is appropriate to issue anti-D Two
Lack of knowledge of when it is appropriate to issue anti-D Two
Junior doctor gives anti-D without knowledge of patients blood group
Junior doctor gives anti-D without knowledge of patients blood group
Use of patient notes in an ID check, in place of the patients
Use of patient notes in an ID check, in place of the patients
A totally different immunoglobulin given instead of anti-D A vial of
A totally different immunoglobulin given instead of anti-D A vial of

: Cases from the 2008 SHOT Report. : NBS. : Cases from the 2008 SHOT Report.ppt. zip-: 76 .

Cases from the 2008 SHOT Report

Cases from the 2008 SHOT Report.ppt
1 Cases from the 2008 SHOT Report

Cases from the 2008 SHOT Report

You are free to use these examples in your teaching material or other presentations, but please do not alter the details as the copyright to this material belongs to SHOT. They have been loosely categorised, but some cases may be appropriate to illustrate more than one type of error

2 Poor decision making / lack of understanding Slide 4 Failure of

Poor decision making / lack of understanding Slide 4 Failure of

checking procedures Slide 15 Sampling / result errors Slide 23 Handling / storage errors Slide 34 Problems with collection Slide 43 Problems with patient ID Slide 46 Laboratory errors Slide 51 Failure to follow guidelines Slide 67 Special requirements Slide 69 Anti-D Slide 75

3 Poor decision making / lack of understanding

Poor decision making / lack of understanding

4 Lack of recognition of paediatric emergency units A neonate required

Lack of recognition of paediatric emergency units A neonate required

emergency transfusion and 20ml was administered from an adult unit of group O RhD negative red cells removed from the blood bank by a registered midwife who had not received transfusion training. The unit was not labelled for emergency use, but was allocated for an adult patient on the maternity unit. The blood was not signed out of the issue fridge and the bedside check was not done. The blood issue fridge was stocked with 2 emergency group O RhD negative paedipacks, which were not used. The baby died the same day, unrelated to the transfusion.

5 Red cells administered instead of platelets A unit of platelets was

Red cells administered instead of platelets A unit of platelets was

prescribed for administration overnight, with a further unit of red cells to be given in the morning. Although the staff nurse believed she had given a unit of platelets, she had collected and transfused a unit of red cells, administering the component over 50 minutes as per the platelet prescription. The prescription form was completed with confirmation of bedside checks. When questioned, the nurse stated she did not know the difference between a bag of red cells and a bag of platelets.

6 FFP administered instead of platelets Red cells, platelets and FFP

FFP administered instead of platelets Red cells, platelets and FFP

were ordered although there was no clinical indication for FFP written in the notes. The patient was prescribed platelets but FFP was collected in error from the transfusion laboratory by a porter and administered to the patient instead. The error was not realised during the 2-person bedside check. It only came to light when the transfusion laboratory contacted the ward to ask why the platelets had not been used.

7 FFP administered instead of platelets FFP, red cells and platelets

FFP administered instead of platelets FFP, red cells and platelets

were requested for an 11-day old patient with sepsis. Platelets were prescribed by the doctor, but a registered nurse mistakenly collected FFP from the laboratory refrigerator. The nurse was reported as looking for a non-cellular component and seeing the FFP in the refrigerator, thought this was platelets. The nurse signed in the register against the platelets, even though the donation number was different. The unit of FFP was transfused on the ward following checks by 2 registered nurses, thinking that this component was platelets. The error was noticed the next day by a BMS when platelets for the patient were found in the platelet agitator in the laboratory.

8 Platelets administered without a prescription Platelets had been

Platelets administered without a prescription Platelets had been

ordered for an 11-year old child for administration the following day, pending a final decision (and prescription) on the ward round. Two units of red cells had already been transfused, but the porter collected the platelets too. The platelets were given by a registered nurse without a prescription.

9 Lack of communication between shifts in SCBU results in baby being

Lack of communication between shifts in SCBU results in baby being

transfused twice A 2-month old premature baby had a haemoglobin of 9.9 g/dl, requiring top-up, and the team on duty that day administered 60ml of red cells. Three days later, another team on the unit noticed the same Hb result, made a decision to transfuse and gave a further 70 ml red cells. There was no indication on the treatment chart that the patient had been transfused, the prescription chart had been filed in the wrong place, and notes were not checked for evidence of previous transfusions.

10 Inadequate management of acute bleeding associated with high INR on

Inadequate management of acute bleeding associated with high INR on

warfarin An elderly woman on warfarin for AF was admitted with a PR bleed. She was found to have Hb of 6.8 g/dl and INR of 7.2. She was given vitamin K 2 mg IV and 3 units of FFP were requested. All 3 units of FFP were taken at the same time and administered over 3 hours. Soon after completion of the third unit the patient developed an itchy erythematous rash and was given IV chlorpheniramine and hydrocortisone. Six hours later the patient was found collapsed and resuscitation was unsuccessful. Postmortem examination showed fresh blood in the bowel and cause of death was given as haemorrhage from large bowel. In spite of blood results and persistent hypotension, this patient received no intravenous therapy apart from the FFP, and no blood transfusion was given, though 4 units had been crossmatched.

11 Over-estimation of blood loss from GI bleeding leads to massive

Over-estimation of blood loss from GI bleeding leads to massive

overtransfusion An elderly inpatient had a coffee ground vomit and some melaena. IV fluids were administered and an FBC showed as Hb of 14.3 g/dl. Her Hb the previous day had been 14.7 g/dl. Observations were initially stable, but her BP suddenly dropped and 2 units of red cells were transfused. Twenty minutes later, after another haematemesis, a further 2 units of red cells were transfused. No repeat FBC samples were taken due to poor venous access. Two hours later, the BP was stable, and a further 2 units were transfused. The Hb later that day was 16.6 g/dl, rising to 18.3 g/dl that night, and 20.8 g/dl the following afternoon. The patient died on the evening of the following day.

12 Overestimation of blood loss from acute GI bleed A patient was

Overestimation of blood loss from acute GI bleed A patient was

admitted to the ED with a GI bleed. Hb on admission was 12.1 g/dl. 2 units of emergency blood were given, followed by 6 units of crossmatched blood over the next 12 hours. The FBC was not re-checked until all 8 units had been transfused, by which time the Hb was 18.5 g/dl

13 Overtransfusion and subsequent venesection of a 1-year old under

Overtransfusion and subsequent venesection of a 1-year old under

shared care A small 1-year old undergoing shared care attended her DGH for a top-up transfusion of 2 paediatric units of red cells as recommended by the tertiary referral centre. This was written on the prescription sheet as 2 units and no volume specified. As she had not previously been transfused at the DGH, and being over 1 year old, the laboratory supplied adult red cell packs. Four days post transfusion, her Hb was excessively high and the error was discovered. Her Hb continued to rise and necessitated venesection of the patient.

14 Confusion over correct dosage of cryoprecipitate A patient was

Confusion over correct dosage of cryoprecipitate A patient was

administered 10 packs of pooled cryoprecipitate rather than the recommended 2 packs. The order for the blood component had been placed by a consultant haematologist using old single pack units rather than pooled packs, leading to confusion in the laboratory.

15 Failure of checking procedures

Failure of checking procedures

16 Lack of understanding of what a bedside check involves, and why A

Lack of understanding of what a bedside check involves, and why A

67-year old female patient in a side room was prescribed a transfusion. A trained housekeeper took the correct patient documentation to the issue fridge, but collected a unit of blood for a different patient with the same first and last name. The unit was checked outside the side room, against the compatibility statement, by two nurses. The transfusion record was completed by both nurses indicating that all checks had been completed. One nurse then entered the room and administered the blood without a bedside ID check. The patient was group O RhD positive and received a unit of A RhD positive red cells. The already severely ill patient developed respiratory problems and died later that day, though there was no record of haemolysis.

17 No patient ID check when administering group-specific units A 77-year

No patient ID check when administering group-specific units A 77-year

old man with a ruptured aortic aneurysm was admitted via ED straight to theatre for emergency surgery. An anaesthetist collected what he thought was emergency group O RhD negative blood from the theatre fridge, which was in fact group B RhD positive blood issued for a specific patient. A second anaesthetist administered the blood without any ID checks. The transfusion laboratory then issued group specific blood for the patient, who was group A RhD positive. A consultant anaesthetist notice the discrepancy in blood groups and highlighted the error made earlier. There was no evidence of a transfusion reaction or haemolysis, and the patient died as a result of his ruptured aneurysm.

18 Acute haemolytic reaction in a frail elderly man administered

Acute haemolytic reaction in a frail elderly man administered

ABO-incompatible red cells A 91-year old male patient who had sustained a head injury and intracranial bleed was prescribed a transfusion, administered after midnight. The incorrect unit of red cells was collected by an untrained registered nurse. Pre-transfusion checks were conducted by 2 registered nurses, against the compatibility statement, which was signed, timed and dated. The patient was wearing a wristband, but this was not used in the checking process. The patient, who was group O RhD positive, received group B RhD positive red cells. After 100ml of the transfusion, he became agitated and pyrexial and the transfusion was discontinued. He died 9 days later and the coroner concluded that death was due to causes other than the transfusion.

19 Lack of positive ID check at collection and administration A 92-year

Lack of positive ID check at collection and administration A 92-year

old male patient with a GI haemorrhage was prescribed a blood transfusion in the ED. Correct documentation was taken to collect the units, but was not used to identify the unit at the issue refrigerator. The incorrect unit was collected and was checked by 2 staff nurses against accompanying paperwork, but not checked against any other patient ID as the patient was not wearing a wristband and was unable to participate in the checks himself. The patient was group B RhD positive and the unit was group A RhD positive. After 50ml of the transfusion the patient developed an acute reaction and the transfusion was stopped. He developed haemolysis but recovered fully.

20 Lack of ID checks at patients side A haematology patient required a

Lack of ID checks at patients side A haematology patient required a

second unit of red cells, so the registered nurse looking after the patient co-opted a second registered nurse to perform the patient ID check. All the documentation was completed and signed by both nurses at the nurses station. The first nurse then took the unit into the 6-bedded bay alone, and administered the blood to the patient opposite the one for whom it was intended, without a bedside ID check. An A RhD negative patient was thus transfused with a unit of group O RhD positive red cells. No transfusion observations were conducted. Both nurses had received transfusion training within the previous 12 months.

21 No patient ID check made in emergency situation when box of blood for

No patient ID check made in emergency situation when box of blood for

two patients delivered to ED Blood for two patients was sent in the same box from the transfusion laboratory to the ED. A 37-year old male trauma patient required urgent transfusion and blood for a different patient was removed from the box and administered by an anaesthetist, without checking the details of the patient in any way. Each member of staff thought the other had performed the ID checks. The patient, who was group O RhD negative, received a unit of group O RhD positive red cells. He died due to his major trauma.

22 Bedside check omitted in favour of a treatment room check Forms and

Bedside check omitted in favour of a treatment room check Forms and

documentation for a transfusion were completed and signed by two registered nurses in the treatment room. One of the nurses then took the unit and connected it to a different patient, also awaiting transfusion, without a bedside patient ID check. A little later, blood was being prepared for transfusion to this patient, who was found to already have a transfusion running, so the error was discovered. Both patients were group B RhD positive.

23 Sampling / Results errors

Sampling / Results errors

24 Doctors phlebotomy error results in 2 unit ABO-incompatible

Doctors phlebotomy error results in 2 unit ABO-incompatible

transfusion An elderly patient was bled and grouped as B RhD positive, and transfused with 2 units of B RhD positive red cells for anaemia (cause not given). This patient had been bled by a doctor during normal working hours. A subsequent sample that grouped as A RhD positive was rechecked and proved to be the correct blood group. The wrong patient had been bled when the original sample was taken. Fortunately the patient did not suffer any ill effects from 2 units of ABO-incompatible blood.

25 Phlebotomists patient ID error results in 3 unit ABO-incompatible

Phlebotomists patient ID error results in 3 unit ABO-incompatible

transfusion An elderly gentleman required an amputation for gangrene and was grouped as B RhD positive. 3 units of B RhD positive red cells were transfused in the perioperative period. A post-operative sample taken a few days later prior to a laparotomy grouped as O RhD positive. The patient had in fact suffered some respiratory problems, further anaemia and hyperbilirubinaemia following his original transfusion, but these had been attributed to his multiple co-morbidities and possible fluid overload. The patient eventually died of complications unrelated to his ABO-incompatible transfusion. The incorrect sample had been taken from the wrong patient by a phlebotomist.

26 Acute HTR from ABO-incompatible transfusion comes to light 11 years

Acute HTR from ABO-incompatible transfusion comes to light 11 years

later The patient, an elderly male, grouped as O RhD negative, which was discrepant with the original blood grouping result held in the computer system from 11 years earlier, when he was grouped as A RhD negative. Further investigation revealed that 11 years earlier he had received 2 units of A RhD negative red cells resulting in a haemolytic episode with renal failure requiring dialysis. A full recovery was made, and it was not clear from the records whether the transfusion was implicated at the time. The patient is now established as group O RhD negative.

27 Doctors phlebotomy error in emergency situation A middle-aged man

Doctors phlebotomy error in emergency situation A middle-aged man

with hepatic failure and perforated ulcer grouped as A RhD positive. 6 units of red cells were crossmatched, 10 units of FFP and 2 units of platelets were issued, all A RhD positive. The FFP and platelets were given, but fortunately the red cells were not, as subsequent samples revealed that the patient was in fact group O RhD positive and that the doctor had bled the wrong patient. The patient suffered no reaction.

28 Incorrect Hb level and group following patient ID error A middle-aged

Incorrect Hb level and group following patient ID error A middle-aged

gentleman with brain metastases and seizures had samples taken for a repeat haemoglobin, which revealed that his Hb had dropped from 13.7 to 8.9 g/dl. The patient was crossmatched using a group & save sample taken at the same time as the Hb sample and transfused 2 units of O RhD positive red cells. This resulted in a post-transfusion haemoglobin level of 15.3 g/dl. A historical blood group (possibly from another hospital) was subsequently discovered for this patient, who turned out to be really AB RhD positive. It was clear that the wrong patient had been bled, as both the Hb result and blood group were incorrect. Fortunately, the patient suffered no reaction to the transfusion of O RhD positive red cells.

29 Transfusion and multiple investigations based on a drip arm

Transfusion and multiple investigations based on a drip arm

haemoglobin A patient was admitted with dizziness and collapse and a history of CVA. The patients Hb was 11.4 g/dl on admission, but had apparently dropped to 6.9 g/dl the following day. The FBC was not repeated and the patient was transfused 2 units of red cells even though there was no evidence of blood loss. In addition, various investigations were requested post transfusion, including abdominal ultrasound and haemolysis screen. An inpatient referral was made to a consultant haematologist, who assessed the patient and questioned the validity of the Hb result. A repeat sample showed an Hb of 13.1 g/dl, and further investigation revealed that the second sample had been taken from the same arm as the drip.

30 Transfusion based on a year-old haemoglobin result Two units of blood

Transfusion based on a year-old haemoglobin result Two units of blood

were requested for an orthopaedic trauma case because of low pre-op haemoglobin of 9.7 g/dl. The blood was provided and transfused. A phone call to the laboratory to check the pre-op Hb result and coagulation screen alerted the staff to the fact that the samples sent had been clotted and therefore could not be analysed. The result used to request the transfusion had in fact been taken on exactly the same date, but one year earlier. The post-operative Hb was 13.9 g/dl.

31 Spurious pancytopenia results in unnecessary hospital admission and

Spurious pancytopenia results in unnecessary hospital admission and

prophylactic platelet transfusion A patient was bled for an FBC by a GP practice nurse after presenting with arthralgia and a rash. The results showed a pancytopenia with Hb 9.2 g/dl, WBC, 0.4 x 10^9/l and platelets of 7 x 10^9/l, with no evidence of a clot in the sample. The patient, who appeared well, was admitted to a medical ward out of hours where the admitting junior doctor telephoned the duty consultant haematologist who advised isolation because of the neutropenia and a platelet transfusion. The patient was reviewed by the consultant haematologist the next day and was found to be well, apyrexial with no purpura or petechiae, and a repeat FBC showed Hb 13.4 g/dl, WBC 8.2 x 10^9/l and platelets of 351 x 10^9/l

32 Short sample gives spurious result leading to 3-unit transfusion A

Short sample gives spurious result leading to 3-unit transfusion A

woman requesting a termination of pregnancy had samples for FBC and Group & Save taken by a phlebotomist. A small sample was taken into a paediatric bottle because of poor venous access. The Hb was reported as 6.3 g/dl and the woman was admitted that night for pre-op transfusion of 3 units of blood. No repeat FBC was taken before transfusion, and no investigations into the cause of anaemia were requested. Two days later the haemoglobin result was 15.6 g/dl, suggesting that the previous FBC had been erroneous and that transfusion had been unnecessary.

33 Unnecessary transfusion based on obviously erroneous result A patient

Unnecessary transfusion based on obviously erroneous result A patient

was admitted to the ED and samples sent for FBC and crossmatch. A Hb result of 2.7 g/dl was telephoned, and the BMS advised repeating the sample as the result was suspect. However, this was not done, and the patient was immediately transfused with 2 units of red cells. On admission to the ward a further FBC was taken, showing a Hb of 13.7 g/dl. However 4 further units had been prescribed and were given, resulting in a post-transfusion Hb of 18.8 g/dl.

34 Handling / storage errors

Handling / storage errors

35 Transfusion continued despite leak from port exposing contents to

Transfusion continued despite leak from port exposing contents to

contamination A patient was transfused with 2 units of red cells and the nurse giving the units noticed that blood was leaking from the port into which the giving set was inserted. She continued the transfusion rather than stopping it, and informed the transfusion laboratory after the event. The bags were returned to the local Blood Establishment laboratory for investigation but no defect was found. The patient suffered no ill effects.

36 Lack of knowledge leads to inappropriate concerns and non-compliance

Lack of knowledge leads to inappropriate concerns and non-compliance

with basic protocols A unit of blood was removed from the blood bank by an auxiliary nurse, who did not see that it had expired at midnight the previous day. The 2 registered nurses who undertook the pre-administration check were worried that the donor and recipient groups were not the same, even though the accompanying documentation clearly stated that the blood groups were different but compatible. The nurses thought that they had completed the checks when they were distracted by the blood group problem and telephoned the laboratory for advice. They then administered the blood without checking the expiry date. The patient suffered no ill effects, and the error was discovered by the same nurses when they prepared to administer the next unit of blood.

37 In absence of security normally provided by an electronic system,

In absence of security normally provided by an electronic system,

basic checks are omitted A nurse was sent to collect 1 unit of red cells from the issue fridge, but the electronic blood tracking system was down. The BMS on duty used the manual override to open the refrigerator and handed the unit to the nurse. The expiry date was not checked either by the BMS or the nurse during this process. The pre-transfusion check was performed at the patients bedside. The nurse stated that the expiry date had been checked, but the fact that the unit had expired the previous night was not recognised. The patient was transfused with no ill effects and the error became apparent during a refrigerator stock check later that morning.

38 Slow transfusion due to poor venous access not attended to

Slow transfusion due to poor venous access not attended to

appropriately in overnight transfusion A patient was prescribed 4 units of red cells for anaemia. A porter collected the 3rd unit at 0100 and it was commenced at 0115. The blood ran slowly, so the cannula was re-sited and transfusion recommenced at 0550. The midwife on the day shift tried to flush the cannula to complete transfusion, which was documented as stopped at 1000, incomplete. The prolonged transfusion time was only noticed when the TP was auditing the documentation process. The unit had been administered over a total of 9 hours.

39 Overnight transfusion prescribed for 4 hours not monitored and runs

Overnight transfusion prescribed for 4 hours not monitored and runs

for >10 hours A unit of red cells was collected from the blood bank at 2110. According to documentation, transfusion was commenced at 2130 by a trained trust bank nurse and an agency nurse, with the prescription for transfusion over four hours. The transfusion was not recorded on a fluid balance chart. The bank nurse went home at 2300, and the agency nurse took responsibility for the patient. Day staff took over at 0800, and the unit was still running. The transfusion was eventually stopped at 0830, more than 10 hours after commencement.

40 Undue responsibility placed with porter, and lack of liaison about

Undue responsibility placed with porter, and lack of liaison about

critical patient transfer A patient in ITU was bleeding with associated coagulopathy, requiring large volumes of plasma and red cells. Transfer to another hospital was arranged for specialist treatment, and 4 units of red cells were to be available for the transfer. The porter collected 4 red cells from the blood bank, but packed them in a bag containing dry ice and delivered them to the ITU. The laboratory were not aware that the blood had been removed. The patient received 1 unit of blood before transfer, and a further 2 units during transit. On arrival, the remaining unit was found to be frozen. The patient suffered no ill effects.

41 Red cell unit returned to stock despite being out of controlled

Red cell unit returned to stock despite being out of controlled

storage for over one hour. 6 units of red cells were issued to theatre, where 3 were transfused. The remaining 3 units were placed in the theatre satellite blood refrigerator and later returned unused to the hospital transfusion laboratory. Subsequently, 1 unit was issued and transfused to another patient. A retrospective check revealed that the re-issued unit had been out of controlled storage for more than 1 hour. The recipient showed no ill effects. The transfusion laboratory now quarantines all blood component returns from satellite fridges to confirm that the cold chain has been maintained before re-issue.

42 Undue responsibility placed with porter, compounded by ignoring the

Undue responsibility placed with porter, compounded by ignoring the

electronic tracking system A unit of blood was collected from the blood bank at 1715. The patient was not cannulated, and the doctor was unable to achieve access despite several attempts. The porter returned the blood to the issue refrigerator at 2020, but did not inform the duty BMS that the unit had been out of controlled storage for more than 3 hours. A warning from the electronic blood tracking system was ignored, and the unit was replaced with the rest of the allocated blood. The same unit was re-taken at 2300, and the electronic blood tracking warning alert was again ignored. The unit was administered to the patient at 2330, more than 6 hours after initial removal from controlled storage.

43 Problems with collection

Problems with collection

44 Incorrect documentation used to collect red cells from issue

Incorrect documentation used to collect red cells from issue

refrigerator An anaesthetist asked an ODP to collect 2 units of blood crossmatched for a patient in theatre. The ODP filled out a Blood Collection Form with details from a wristband left in the anaesthetic room, assuming that this wristband was from the patient in theatre. In fact the wristband had been removed from a patient on the previous list. The ODP gave the form to a theatre support worker who correctly collected the units of blood for the patient named on the form. The anaesthetist checked the blood against the accompanying compatibility report only and did not check the patient ID against the patients wristband. The patient was group O RhD positive, and the unit administered was group O RhD negative.

45 Incorrect units collected in place of emergency group O RhD negative

Incorrect units collected in place of emergency group O RhD negative

blood A patient was rushed to maternity theatres for a Caesarean Section as she was starting to haemorrhage. The anaesthetist requested emergency group O RhD negative blood. A midwife, who had received transfusion training, went to the maternity theatres satellite blood refrigerator and collected two units of blood from the top drawer without any checks, assuming that it was the emergency blood. The two units were given rapidly. The anaesthetist commented that the blood was group O RhD positive, but as the patient was group A RhD positive, the anaesthetist was happy it was compatible. it was only when they took it down that they realised the blood was allocated to a different patient, and was not the emergency blood at all.

46 Problems with patient ID

Problems with patient ID

47 One patient  two wristbands A 69-year old male patient was in ITU

One patient two wristbands A 69-year old male patient was in ITU

unconscious following major surgery. The patient had a wristband on each wrist, one of which contained details for another patient. The correct bedside checking procedure was completed at the bedside, but the patient ID was taken from the wrong identification label on his wrist. The patient, who was group A RhD negative, received a unit of group O RhD positive red cells intended for another patient

48 Dual registration results in misgrouping of a massively transfused

Dual registration results in misgrouping of a massively transfused

neonate A very sick 2-day old neonate with hydrops foetalis grouped as B RhD positive, and was given large volumes of group O RhD negative blood in the neonatal period. A second sample was taken and details entered into the neonatal department computer system, which interfaced with the main hospital computer system. However, the previous record number was not retrieved, and a new hospital number was created by the neonatal system. The second sample grouped as O RhD positive, and the neonate subsequently received group O FFP and platelets. Due to the 2 hospital numbers, there was no record of previous transfusions on the second sample, and the error was spotted when someone queried why they were transfusing O RhD positive components when they had previously transfused O RhD negative components. There was no haemolytic reaction recorded. The patient was extremely sick and later died of other complications of hydrops foetalis.

49 Wrongly labelled unit transfused despite original error having been

Wrongly labelled unit transfused despite original error having been

detected and corrected When the patient was admitted, his DOB had been incorrectly entered on the Patient Information Management System. He was prescribed FFP, and during the pre-transfusion check he mentioned that his DOB was incorrectly recorded. The FFP was returned to the laboratory. The patient was then correctly re-admitted onto the PIMS, and the FFP was re-ordered. Unfortunately, the porter collected the incorrectly labelled units of FFP which were still on the bench in the laboratory. The nurses assumed that the FFP was labelled correctly and did not repeat the bedside administration check before transfusing it. The patient was not wearing an ID band during the transfusion episode, as the old incorrect one had been removed and the new correct one had been generated but not attached.

50 A pointless check between two incorrect documents generated by the

A pointless check between two incorrect documents generated by the

same computer system A clerical error occurred in the laboratory while inputting the unit number for the (laboratory generated) prescription sheet and compatibility label. The details on the original request form were correct. The nurses administering the component failed to carry out a patient identification procedure; they checked the prescription form against the compatibility label, both of which contained the incorrect hospital number. They did not check the documentation with patient ID, as the patient was not wearing a wristband.

51 Laboratory errors

Laboratory errors

52 Electronic records and automation highlight historical error At

Electronic records and automation highlight historical error At

authorisation of a blood grouping result, the pathology computer flagged a mismatch with historical data, which stated that the patient was AB RhD positive. The current sample grouped as O RhD positive, and a repeat sample also proved to be O RhD positive. The historical search identified that 2 units of AB RhD positive red cells had been transfused to this patient a year earlier. Further investigation revealed that two samples received at the same time a year earlier had been transposed in the laboratory, resulting in the transfusion of 2 units of AB RhD positive red cells to the O RhD positive patient, and also the transfusion of 3 units of O RhD positive red cells to an AB RhD positive patient. Neither patient was reported as suffering any ill effects following transfusion of ABO-incompatible units

53 When IT fails, electronic issue cannot be used A 19-year old female

When IT fails, electronic issue cannot be used A 19-year old female

was admitted as an emergency with head trauma. The sample was tested using routine automation but the interface froze and the result was entered manually onto the laboratory computer system (LIMS). Results from the wrong patient were entered. The blood was then allocated to the patient using electronic issue. 4 units of group A RhD positive red cells were transfused to this patient, who was actually O RhD positive. The error was identified when the patient developed symptoms of a HTR with red urine and falling haemoglobin. Fortunately, she made a full recovery from her ABO-incompatible transfusion.

54 Competency assessment on blood group anomalies must form part of

Competency assessment on blood group anomalies must form part of

training A grouping discrepancy was highlighted on the automated group of a 74-year old patient requiring transfusion for anaemia. The forward group was A, but there was no reaction with the B cells in the reverse group. The BMS rechecked the group and thought that there was a weak reaction with anti-B, and interpreted the group as AB. However, as there was some uncertainty, the BMS selected group A red cells for crossmatch and transfusion. Further testing of the sample by laboratory staff the following day confirmed that the group was A. It was felt that inexperience led to the mistake.

55 The difficulties encountered with cases of AIHA A 93-year old female

The difficulties encountered with cases of AIHA A 93-year old female

with AIHA was transfused 4 units of group A RhD positive blood rather than group O RhD positive blood because of a laboratory error in result interpretation. The patient sample had been tested overnight, but the results were held for authorisation as the DAT was 4+ and the antibody screen was 3+. The next morning the card was incorrectly interpreted as group A RhD positive. The patient was reported (by telephone) by a NHSBT RCI reference laboratory as having autoantibodies and anti-E. Four units of A RhD positive, E(-), K(-) units were crossmatched for the patient. All units were incompatible, as was the patients auto, but were issued for transfusion. The error was noticed when the paper copy of the RCI report arrived. No adverse effects were noted that could be attributed to the transfusion.

56 RhD types must not be assigned on one weak reaction A patient

RhD types must not be assigned on one weak reaction A patient

initially gave a weak reaction with anti-D reagent and was reported as RhD positive without further investigation. Two units of group O RhD positive red cells were transfused and all subsequent samples grouped as strongly RhD positive. Over a three week period, 14 O RhD positive red cells and 6 O RhD positive platelets were transfused. Several months later the patient presented as O RhD negative with anti-D. Genotyping at BGRL confirmed the patients as RhD negative.

57 Take due care when selecting blood for special patient groups Two

Take due care when selecting blood for special patient groups Two

units of blood were ordered from NHSBT; 1 unit for a neonatal exchange transfusion and the other a phenotyped unit for a child with thalassaemia major. The duty BMS issued the irradiated unit, specified for exchange transfusion, to the thalassaemia major patient, and the non-irradiated phenotyped unit for the exchange transfusion. The error was discovered when the paediatrician realised that they did not have enough blood to complete the exchange transfusion. The child with thalassaemia major did not actually receive any blood as the mistake had been identified prior to commencement of her transfusion.

58 Take due care when selecting platelets for special cases NHSBT

Take due care when selecting platelets for special cases NHSBT

delivered 2 ATDs of platelets for 2 different patients. The BMS transposed the units in the laboratory and issued a pack of HLA-matched platelets ordered for a haematology patient, to the other patient, who was bleeding. Fortuitously, the platelets were ABO-compatible

59 Is causing less distress to a paediatric patient a valid reason for

Is causing less distress to a paediatric patient a valid reason for

using less safe practice ? While a 9-month old male patient was in the anaesthetic room prior to surgery, blood was taken for a Group & Save. This is the usual procedure to avoid distressing younger children prior to elective surgery. A rapid manual group was performed in the laboratory, interpreted (incorrectly) and authorised by a BMS as group O RhD positive with a negative antibody screen. Two units of O RhD positive red cells were issued and transfused. A repeat sample from the patient, tested by the routine automated method in the laboratory, showed that the patient was actually group O RhD negative.

60 IT warning flags are only helpful prompts  staff must understand the

IT warning flags are only helpful prompts staff must understand the

reasons behind protocols A patient had been transfused on 28th Jan. According to local policy the sample was unsuitable for further use from 30th Jan. Despite this, the sample was used to serologically crossmatch blood on 3rd Feb, the computer indicating that electronic issue was not available. The 2 members of staff involved in the incident were senior members of the haematology department working in blood transfusion out of hours. It was clear that they did not understand the reason for the computer indicating that electronic issue was unavailable. The blood was transfused uneventfully.

61 The importance of antibody history A patient arrived in the ED with a

The importance of antibody history A patient arrived in the ED with a

GI bleed and 2 units of flying squad O RhD negative blood were used. A blood group, antibody screen and retrospective crossmatch on the transfused units was performed. The antibody screen and crossmatch were negative, but the on-call BMS noticed that the patient was known to have anti-Jka and anti-f. The ward phoned later to ask for more blood to be crossmatched. The BMS crossmatched unselected units as the current antibody screen was negative, and all units were crossmatch-compatible. The patient received 3 units of A RhD positive blood. The incident was investigated the following day and all five transfused units were found to be Jk(a+). The flying squad units and 2 of the A RhD positive units were f(+). The patient died from the underlying clinical condition.

62 The need for complete documentation Six units of blood were issued

The need for complete documentation Six units of blood were issued

using emergency procedures for a patient admitted with a GI bleed. Full compatibility testing was completed retrospectively. The antibody screen was positive, and 1/6 units was incompatible. The BMS immediately contacted the clinical area to recall the units, but 4, including the incompatible unit, had already been transfused. Further investigation revealed that the patient was already known to have anti-C+D+E, but the critical notes in the laboratory had not been updated with this information. There was no adverse reaction reported

63 The danger of manual transcription of results when the computer is

The danger of manual transcription of results when the computer is

down Following an urgent request for blood for a patient with cranial trauma going to surgery, the on-call BMS manually transcribed incorrect blood grouping results when the laboratory computer interface froze Two units of group A red cells were transfused to a group O patient who subsequently developed red urine and falling Hb, but otherwise made a complete recovery.

64 Multiple errors lead to transfusion of red cells of the wrong ABO

Multiple errors lead to transfusion of red cells of the wrong ABO

group post BMT A group A RhD positive patient received a bone marrow transplant from a group O RhD positive donor. Despite appropriate prior notification by the clinical team, the laboratory computer system was not updated to warn of the new requirement. 6 units of group A RhD positive red cells were issued during routine working hours over the next 2 months. Following receipt of a further notification from the clinical area, the LIMS was updated. However, because of failure to consult the historical record, a further 4 units of A RhD positive red cells were issued over the next 3 months before the error was noticed. The patient experienced no ill effects.

65 Cryoprecipitate mistakenly issued instead of FFP An urgent request for

Cryoprecipitate mistakenly issued instead of FFP An urgent request for

2 units of FFP was received at a time when the LIMS was down. The lone-working on-call BMS erroneously selected and issued 2 pooled packs of cryoprecipitate. The LIMS normally reconciles the component selected with the request at the point of issue, and the laboratory SOP states that 2 members of staff should check each issue. However, only 1 BMS is ever available during the out of hours period.

66 Computer rule leads to transfusion of non-irradiated and CMV-screened

Computer rule leads to transfusion of non-irradiated and CMV-screened

platelets A group A RhD negative male patient with non-Hodgkins lymphoma required irradiated and CMV negative components. This requirement was recorded correctly on the LIMS. Appropriate platelets were ordered from the local blood centre. Due to limited availability of group A CMV negative donations, the blood centre issued a group B RhD positive adult therapeutic dose (this is second choice after group-specific according to national guidelines). However, the hospital LIMS had a built in rule that prevented issue of a different ABO group to the patient. The on-call BMS was distracted by this occurrence and selected an alternative pack of group A non-irradiated, non-CMV-screened platelets, which were subsequently transfused.

67 Failure to follow guidelines

Failure to follow guidelines

68 A hydropic baby is transfused S-positive units, though mother had

A hydropic baby is transfused S-positive units, though mother had

anti-S. It was not checked antenatally. A baby girl was born at 37 weeks gestation following emergency CS. The child was pale, floppy and hydropic with a haemoglobin of 2 g/dl. The baby was group AB RhD positive, the mother group B RhD positive and the father group A RhD positive. Emergency group O RhD negative blood was given (140ml). Laboratory tests showed the baby was DAT positive. The mothers plasma contained anti-S at a titre of 1/8 at delivery, and both father and baby were S-positive. The anti-S had been undetectable at booking, and the mother was not retested at 28 weeks, as she was RhD positive. The emergency O RhD negative blood used was found to be S-positive, and there was a poor increment in Hb following transfusion. The baby received an exchange transfusion of S-negative units, and the hospital now complies with national antenatal guidelines to test all patients at 28 weeks, regardless of RhD type.

69 Special requirements

Special requirements

70 Requestor does not inform the transfusion laboratory that patient is

Requestor does not inform the transfusion laboratory that patient is

pregnant A patient who was 22 weeks pregnant was admitted via the ED with status epilepticus and transferred to ITU. The Hb was 6.7 g/dl and 2 units of red cells were requested and transfused. No diagnosis was given on the request form despite boxes being available to tick (ie Pregnant? Yes/No/Unsure). The following day it was discovered by transfusion laboratory staff that the patient was pregnant, and the units were investigated. One had by chance been CMV negative, but the other had not.

71 Sickle cell disease not stated on request for red cells A patient

Sickle cell disease not stated on request for red cells A patient

was admitted with anaemia and assigned a new hospital number as a new PAS system had recently been installed. No previous transfusion was mentioned on the request, even though the patient had a previous record on another number. The request form stated only anaemia as the indication for transfusion; although the patient suffered from sickle cell disease, the diagnosis was not given, and therefore the laboratory staff were not prompted to look for any previous transfusion history on an older hospital number. The patient was transfused non-phenotyped blood.

72 Transplant centre did not inform referring hospital of ABO-mismatched

Transplant centre did not inform referring hospital of ABO-mismatched

transplant A patient was referred to another trust for a bone marrow transplant. Post-transplant no details of the donor group were sent to the referring trust, so consequently the blood transfusion laboratory there were unaware that the patient had received a major mismatch marrow (the patient was O RhD positive and received a group A RhD positive transplant) and now required FFP and platelets of a different group. The transplant team at the centre was contacted, and faxed through a copy of the transplant protocol. The original distribution list on the protocol document did not include the referring hospital.

73 Laboratory misses fact that there are TWO special requirements A

Laboratory misses fact that there are TWO special requirements A

patient required both CMV negative and irradiated components, and a request was made for 2 units of red cells. CMV negative, but not irradiated units were issued by the laboratory and administered to the patient.

74 BMS omits to issue CMV negative components for pregnant woman with

BMS omits to issue CMV negative components for pregnant woman with

sickle cell disease A patient with sickle cell disease was pregnant, on a high dependency ward. Her haemoglobin was 5 g/dl, and an urgent request was made for 4 units of red cells. Phenotyped units were requested due to the sickle cell disease, but the BMS forgot to issue CMV negative units. The patient received all 4 units overnight, the error being discovered when more units were requested the following day to cover a caesarean section.

75 Anti-D

Anti-D

76 Manual transcription error in the laboratory results in omission of

Manual transcription error in the laboratory results in omission of

anti-D and subsequent D-sensitisation A pregnant patient had bloods taken at booking clinic. The BMS performing ABO and RhD grouping manually recorded the result as RhD positive instead of RhD negative. Consequently, routine antenatal anti-D prophylaxis was not administered, nor would anti-D have been considered for any potentially sensitising event the patient may have suffered. The patient was found later in pregnancy to have developed an immune anti-D

77 Weak D baby recorded as D negative A BMS altered a babys blood

Weak D baby recorded as D negative A BMS altered a babys blood

group on the laboratory computer from weak D to RhD negative in order to facilitate a request for blood made by the clinical area for the baby. Because the babys group was now ostensibly RhD negative, the mother never received an injection of anti-D Ig

78 Lack of knowledge of when it is appropriate to issue anti-D Two

Lack of knowledge of when it is appropriate to issue anti-D Two

midwives separately checked the hospital computer system, which clearly showed the patient to be RhD positive, yet still proceeded to issue anti-D Ig to the patient from a stock held in the clinical area

79 Junior doctor gives anti-D without knowledge of patients blood group

Junior doctor gives anti-D without knowledge of patients blood group

Following a day case gynaecological procedure, a FY2 grade doctor prescribed and administered anti-D Ig from a clinical stock to a patient, without a blood grouping report being available in the clinical area, and without checking to see what the blood group was. The patient was subsequently found to be RhD positive.

80 Use of patient notes in an ID check, in place of the patients

Use of patient notes in an ID check, in place of the patients

wristband or verbal confirmation A midwife collected anti-D Ig, and then took it to the wrong patient along with the intended patients notes. She then proceeded to check identification details against the notes rather than with the patient and administered the anti-D.

81 A totally different immunoglobulin given instead of anti-D A vial of

A totally different immunoglobulin given instead of anti-D A vial of

Herpes Varicella Zoster globulin was issued by the transfusion laboratory to the clinical area included in a supply of 250iu anti-D bulk stock. The discrepancy was missed at the bedside checking stage, and a midwife administered the incorrect globulin in place of the indicated 250iu anti-D Ig.

Cases from the 2008 SHOT Report
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