Analysis of incidents highlights need for a redesign of the transfusion process

3 September 2014

There needs to be redesign of the transfusion process by mapping and audit, both locally and nationally, if there is to be an eradication of medical errors according to the SHOT (Serious Hazards of Transfusion) Report 2013.

Annual SHOT data consistently demonstrates errors to be the largest cause of adverse transfusion incidents.

Dr Paula Bolton-Maggs, Medical Director of SHOT said: 'Transfusion is a multistep process involving several different professionals. Mistakes frequently arise due to poor communication between clinical areas and the lab, and between different hospitals, departments within hospitals and between shifts. Mistakes also occur when staff omit essential identification checks.

'We need to make sure the right checks are made, right from the request for blood from the lab to it appearing at the patients’ bedside, so they get the right blood they need. A simple 5 point checklist completed at the patient’s side immediately prior to transfusion would catch many of the errors.'

2751 reports of transfusion incidents and near misses during 2012/2013 were analysed for the SHOT Report 2013. These came from the 99.5% of NHS Trusts and Health Boards across the UK that are registered with the SHOT scheme.

Human factors (i.e. errors), often multiple, were responsible for most of the reports (78%). The most frequent result of error remains the transfusion of an incorrect blood component.

However, more than 3 million transfusions take place annually in the UK and the Report concludes that the current risks from blood and blood component transfusion in the UK remain small with a risk of death at 8 per one million components issued. There have been no transfusion transmitted bacterial infections over the past four years and in 2013 there were no new reported viral transmissions.

The report’s authors make a number of key recommendations for commissioners, pathology managers, laboratory staff, hospital transfusion teams, clinicians and nurses to reduce the number of blood transfusion incidents happening across the UK. These include:

  • A redesign of the whole transfusion process: Annual SHOT data consistently demonstrate errors to be the largest cause of adverse transfusion incidents so it may be better to redesign the transfusion process to design out the medical errors.
  • Don’t give two without review: Transfusion-associated circulatory overload is a significant hazard particularly when elderly or other patients at risk receive several units of blood without review and a check on the Hb level. A clinical review should be undertaken after each red cell unit transfusion. 
  • All ABO-incompatible red cell transfusions to be included as ‘never events’: ABO-incompatible transfusions may be fatal and are absolutely preventable. The two thirds that do not result in harm should be included as reportable ‘never events’.

Rebecca Gerrard from the Patient Blood Management Team at NHS Blood and Transplant, who are responsible for leading regional and national initiatives aimed at promoting safe and appropriate transfusion practice in England and North Wales said: 'We welcome the report’s recommendations. The SHOT UK haemovigilance scheme is hugely important as it helps provide the bigger picture across the NHS. This kind of monitoring and surveillance is vital to identifying trends in practice and demonstrating where there is room for improvement.

'Although the UK has one of the safest blood supply chains in the world, we should never be complacent and should always be looking to ensure the safest and highest quality transfusion practices.'

To read the Annual SHOT Report 2013, visit: www.shotuk.org

Ends

For further information please contact the SHOT office on 0161 423 4208 or email shot@nhsbt.nhs.uk

Notes to Editors

  • SHOT is the United Kingdom’s independent, professionally- led haemovigilance scheme. It started in 1996 and is regarded as the ‘gold standard’ for other schemes. SHOT collects and analyses anonymised information on adverse events and reactions in blood transfusion from all healthcare organisations that are involved in the transfusion of blood and blood components in the United Kingdom.
  • The first SHOT Report published was for events reported in 1996/1997. Then, fewer than 25% of hospitals were registered and just 169 incidents reported. Today, 99.5% of National Health Service Trusts and Health Boards across the UK are registered to report to the SHOT scheme.
  • Over the past 17 years, the categories of evidence gathered through the scheme have been reviewed and updated. The lessons learned from the analysis of the reported incidents from around the UK lead to clear recommendations for all areas of the transfusion process. The principal purpose of SHOT ‘to improve patient safety in blood transfusion’ remains unchanged.