Pres ented by The Yorks hire & Humber R egional Trans fus ion Practitioner Group 1 FY1 PDP Safe Transfusion Practice V1.2 September 2010 Authors: The Yorkshire & Humber Regional Transfusion Practitioner Group
Aim To review real life case studies of transfusion incidents, identifying; What went wrong Why What should have happened C onsequences to the patient/clinician 2 FY1 PDP Safe Transfusion Practice V1.2 September 2010 Authors: The Yorkshire & Humber Regional Transfusion Practitioner Group
Objectives R aise awareness of: S erious Hazards of Transfusion Inappropriate & unnecessary transfusions Transfusion reactions R ecognising how transfusion errors can occur through limitations in knowledge/experience The effects of these on patient outcome Where to go for advice/support 3 FY1 PDP Safe Transfusion Practice V1.2 September 2010 Authors: The Yorkshire & Humber Regional Transfusion Practitioner Group
S erious Hazards of Trans fus ion S HOT S HOT is the United Kingdom s independent, professionally led haemovigilance scheme. S tarted in 1996 and was the first such scheme in the world. S HOT collects and analyses anonymised information on adverse events and reactions in blood transfusion from all healthcare organisationsthat are involved in the transfusion of blood and blood components in the United Kingdom. 4 FY1 PDP Safe Transfusion Practice V1.2 September 2010 Authors: The Yorkshire & Humber Regional Transfusion Practitioner Group
S HOT 2009 R eport- 1279 reports 5 FY1 PDP Safe Transfusion Practice V1.2 September 2010 Authors: The Yorkshire & Humber Regional Transfusion Practitioner Group
S HOT C as es of inappropriate and S HOT C as es of inappropriate and unneces s ary trans fus ion 1996 - - 2009 2009 unneces s ary trans fus ion 1996 6 FY1 PDP Safe Transfusion Practice V1.2 September 2010 Authors: The Yorkshire & Humber Regional Transfusion Practitioner Group
Inappropriate & unneces s ary trans fus ion (I&U) S HOT R eport 2009 There were 92 casesof inappropriate and unnecessary transfusion in 2009 compared with 76 in the 2008 report. This is an increase of 21% since last year. Two patients in this group died following over- transfusion, and this may have contributed to their deaths. The majority of cases relate to lack of knowledge and errors of judgement (often due to inexperience) in clinical staff 7 FY1 PDP Safe Transfusion Practice V1.2 September 2010 Authors: The Yorkshire & Humber Regional Transfusion Practitioner Group
Inappropriate & unneces s ary trans fus ion (I&U) Transfusions given on the basis of erroneous, spurious, or incorrectly documented laboratory testing results for haemoglobin, platelets and coagulation tests. Transfusions given as a result of poor understanding and knowledge of transfusion medicine, such that the decision to transfuse puts the patient at significant risk, or was actually harmful. Under transfusion or delayed transfusion resulting in poorer patient outcome 8 FY1 PDP Safe Transfusion Practice V1.2 September 2010 Authors: The Yorkshire & Humber Regional Transfusion Practitioner Group
Trans fus ion C as e S tudies R ead through each cas e s tudy and cons ider: What went wrong? Why? What should have happened? C onsequences to the patient/clinician? What was the transfusion reaction? L is t your findings on flip chart provided and s elect a s pokes pers on to feedback 9 FY1 PDP Safe Transfusion Practice V1.2 September 2010 Authors: The Yorkshire & Humber Regional Transfusion Practitioner Group
Trans fus ion C as e S tudy 1. Patient dies following trans fus ion E lderly man with chronic renal failure, anaemia and a history of falls attends A&E S ymptomatically anaemic with Hb 6.8 g/dl. C ross matched using a blood sample taken in A&E On ITU after < 100 mLblood had been transfused, developed fever, hypotension, bronchospasm and died a few hours later On inves tigation: Patient blood was group O R hDnegative, he received a unit of A R hDnegative blood. Show slides 11, 12, 13 & 14 following feedback 10 FY1 PDP Safe Transfusion Practice V1.2 September 2010 Authors: The Yorkshire & Humber Regional Transfusion Practitioner Group
Trans fus ion C as e S tudy 1. What went wrong? No checking of patient s ID at the bedside, either with the patient or with the patients wristband. Wrong patient had been bled in A&E resulting in a wrong blood in a tube incident. The sample was labelled for the intended patient. Why? Transfusion sample protocol not followed. What s hould have happened? All patients being sampled must be positively identified. R eaction? Acute Haemolytic Trans fus ion R eaction 11 FY1 PDP Safe Transfusion Practice V1.2 September 2010 Authors: The Yorkshire & Humber Regional Transfusion Practitioner Group
S ampling Procedure S tep 1: Ask the patient to tell you their: F ull name and date of birth C heck this information against the patient s ID wristband Get a s econd independent check when the patient is uncons cious / compromis ed 12 FY1 PDP Safe Transfusion Practice V1.2 September 2010 Authors: The Yorkshire & Humber Regional Transfusion Practitioner Group
S ampling Procedure S tep 2: C heck the patient s ID wristband against documentation e.g. case notes or transfusion request form EXAMPLE REQUEST FORM F irst name S urname Date of birth Hospital number 13 FY1 PDP Safe Transfusion Practice V1.2 September 2010 Authors: The Yorkshire & Humber Regional Transfusion Practitioner Group
S ampling Procedure Only bleed one patient at a time Do NOT use pre-labelled tubes Hand write the sample tube before leaving the patients side! NB : Do not take s amples from a IV drip arm. 14 FY1 PDP Safe Transfusion Practice V1.2 September 2010 Authors: The Yorkshire & Humber Regional Transfusion Practitioner Group
Trans fus ion C as e S tudy 2. 67 year old man diagnosed Prostate cancer Visited GP as felt tired for some time Hb 7.6g/dl. - admission arranged 2/3 days later as a day case for 3 unit blood transfusion 9am - arrives on day unit & informs staff he is the main carer for his disabled wife, anxious transfusion is completed as soon as possi ble 11am - group & cross match sample taken 2pm - blood sample arrives in transfusion lab 4pm - 3 units available for collection 5.45pm - 1st unit commenced and transfused within 2 ½ hours uneventful 8.15pm - patient very anxious to go home, however, 2 more units still to be transfused. Day unit due to close at 9pm Show slide 16 following feedback 15 FY1 PDP Safe Transfusion Practice V1.2 September 2010 Authors: The Yorkshire & Humber Regional Transfusion Practitioner Group
Trans fus ion C as e S tudy 2. What happened next? Decision made to transfuse both units together, one in each arm. Patient found collapsed in chair 15 minutes into transfusion, developed rash on trunk and anterior aspects of legs, which subsided over the next few hours. Transfusion aborted. S pRpersuaded patient to stay overnight for observation (none done by nursing staff). Discharged the following morning by S pR . Incident/ decis ion not documented in patients medical notes and not reported to trans fus ion lab as a trans fus ion reaction . Discharge letter stated Bilateral transfusion to expedite discharge 16 FY1 PDP Safe Transfusion Practice V1.2 September 2010 Authors: The Yorkshire & Humber Regional Transfusion Practitioner Group
Trans fus ion C as e S tudy 3. F ailure to check patient his tory ’ Elderly patient with history of heart failure, admitted for routine weekly transfusion No beds on haematology ward Transferred to surgical day ward by bed manager Transfusion prescribed by haematology Dr (first day in post) no evidence of clerking/checking patient history, no diuretic cov er Transfusion commenced on surgical day ward. When day ward closed , transferred to private ward overnight (during transfusion) P atient developed acute S OB within 2 hrs of completion of transf usion Received oxygen, bronchodilators and diuretics Chest x - ray and E.C.G performed Consultant haematologist informed following day, completed adver se event form. Patient recovered and discharged next day Show slides 18 & 19 following feedback 17 FY1 PDP Safe Transfusion Practice V1.2 September 2010 Authors: The Yorkshire & Humber Regional Transfusion Practitioner Group
Trans fus ion As s ociated C irculatory Overload (TAC O) Definition: Any four of the following occurring within 6 hrs of trans fus ion: Acute respiratory distress Tachycardia Increased blood pressure Acute or worsening pulmonary oedema E vidence of positive fluid balance S HOT 2008 18 FY1 PDP Safe Transfusion Practice V1.2 September 2010 Authors: The Yorkshire & Humber Regional Transfusion Practitioner Group
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