Transcript PPT format
RESULTS FROM THE
2006
SHOT REPORT
SHOT report 2006
Cumulative data 1996 – 2006
Comparison of Report Types 1996 – 2006
Mortality & morbidity 1996 – 2006
Death definitely due to transfusion (Imputability 3) Death probably due to transfusion (Imputability 2) Death possibly due to transfusion (Imputability 1)
Total
47 15 47
IBCT
7 4 13
ATR
2 4 7
HTR
6 1 1
PTP
1 0 1
TA GVHD
13 0 0
Subtotal 1
Major morbidity definitely or probably due to transfusion reaction Minor or no morbidity due to transfusion reaction
109
315 3324
24
100 2582
13
17 387
8
29 280
2
13 31
13
0 0
Subtotal 2 3639 2682 404 309 44 0
Outcome unknown 15 11 3 1 0 * Excludes 7 cases from 1998/99 which were not classified 0
TOTAL 3763 2717 420 318 46 13 TRALI
8 6 25
39
118 38
156
0
195 TTI
10 0 0
10
38 6
44
0
54
Major morbidity was defined as the presence of one or more of the following;
Intensive care admission and / or ventilation
Dialysis and / or renal impairment
Major haemorrhage from transfusion-induced coagulopathy
Intravascular haemolysis
Potential risk of D sensitisation in a female of child-bearing potential
Incorrect blood component transfused (IBCT) All reported episodes where a patient was transfused with a blood component or plasma product which did not meet the appropriate requirements or that was intended for another patient
ABO incompatible red cell transfusions
Analysis of 400 IBCT cases in 2006 Type of IBCT Event (2006 Report)
‘Wrong Blood’ Events
Number (%) 54
(14%) Other pre-transfusion testing errors Special requirements not met
28
(7%) Incorrect group given to ABO/D mismatched transplant patients
8
(2%)
108
(27%) Inappropriate or unnecessary transfusion ‘Unsafe’ transfusion due to handling or storage errors Events relating to administration of anti-D Immunoglobulin
Total 51
(13%)
74
(19%)
77
(19%)
400
Errors associated with Anti-D in 2006 Type of event Total
Omission or late administration of anti-D Ig Anti-D Ig given to D positive patient Anti-D Ig given to patient with immune anti-D Anti-D Ig given to mother of D negative infant Anti-D Ig given to wrong patient Expired anti-D Ig given Wrong dose of anti-D given Other (laboratory errors)
26 19 13 9 4 2 2 - Total cases 77 Total errors
79
Lab Site of Error Midwife Medic 7 19 - 12 7 - 1 1 2 6 8 - 8 1 4 2 - - - - - - 1 - -
37
-
41
-
1
Summary of Blood Transfusion Laboratory Errors
Total errors Wrong sample Trans cription Interpr etation Wrong Blood – ABO Wrong Blood - Others ABO mismatched transplant Special requirements not met Inappropriate transfusion Anti-D errors Unsafe transfusion Other pre-tx testing errors
Total errors
7 20 3 42 - 42 13 29
156
3 - - - - - - -
3
3 4 - - - 2 - -
9
0 - - - - 10 - 1
11
Component selection errors - 8 - 42 - 5 - -
55
Labelling Procedural errors Testing - - 1 5 - - - - - -
5
3 3 - - 10 13 23
52
1 - - 15 - 5
21
Acute transfusion reactions Acute transfusion reactions are defined in this report as those occurring at any time up to 24 hours following a transfusion of blood or components, excluding cases of acute reactions due to incorrect component being transfused, haemolytic reactions, transfusion-related acute lung injury (TRALI) or those due to bacterial contamination of the component.
Acute Transfusion Reactions - 2006 Reaction type Isolated Febrile RBCs (39) Plts Apheresis (11) Plts Buffy Coat (8) FFP (22) 18 1 0 0 Multiple (4) Buffy Coats (1) 0 1 Minor Allergic Anaphylactic / Severe Allergic TACO 3 11 1 Hypotension Febrile with other symptoms Rate per 100,000 units 0 6 2.01 3 5 0 0 2 11.2 1 7 0 0 0 6.6 3 15 1 3 0 8.2 0 3 1 0 0 - 0 - 0 0 0 0
Haemolytic Transfusion Reactions Haemolytic transfusion reactions are split into two categories: acute and delayed. Acute reactions are defined as fever and other symptoms/signs of haemolysis within 24 hours of transfusion, confirmed by a fall in Hb, rise in LDH, positive DAT and positive crossmatch. Delayed reactions are defined as fever and other symptoms/signs of haemolysis more than 24 hours after transfusion, confirmed by one or more of: a fall in Hb or failure of increment, rise in bilirubin, positive DAT and positive crossmatch not detectable pre-transfusion. Simple serological reactions (development of antibody without pos DAT or evidence of haemolysis) are excluded .
Time relationship to transfusion
Transfusion Related Acute Lung Injury (TRALI) Transfusion Related Acute Lung Injury was defined in this report as acute dyspnoea with hypoxia & bilateral pulmonary infiltrates during or within 6 hours of transfusion, not due to circulatory overload or other likely cause.
Summary of TRALI cases reported
Completed Reports analysed in 2006
12
Withdrawn by reporters
2
Analysed for TRALI
10
Highly Likely
2
Probable
1
Possible
4
Unlikely
3
2006 TRALI reports analysed by age and sex
Clinical Speciality / Diagnosis of TRALI cases
Analysis of components implicated in TRALI
Cases of TRALI with relevant donor antibody analysed by implicated component and by year 2003-2006
Deaths at least possibly due to TRALI and number of suspected TRALI cases by year 2003-2006
Post-Transfusion Purpura Post-transfusion purpura was defined as thrombocytopenia arising 5 - 12 days following transfusion of red cells associated with the presence in the patient of antibodies directed against the HPA (Human Platelet Antigen) systems
Number of cases of confirmed PTP reported to SHOT 1996 - 2006
Transfusion Associated-Graft versus Host Disease Transfusion associated-graft versus host disease is a generally fatal immunological complication of transfusion practice, involving the engraftment and clonal expansion of viable donor lymphocytes, contained in blood components in a susceptible host.
TA-GvHD is characterised by fever, rash, liver dysfunction, diarrhoea, pancytopenia and bone marrow hypoplasia occurring less than 30 days following transfusion. The diagnosis is usually supported by skin/bone marrow biopsy appearance and/or the identification of donor-derived cells, chromosomes or DNA in the patient’s blood and/or affected tissues.
Number of cases of TA-GvHD reported to SHOT 1996 - 2006
Transfusion transmitted infections A report was classified as a TTI if, following investigation:
•
The recipient had evidence of infection post-transfusion, and there was no evidence of infection prior to transfusion and no evidence of an alternative source of infection;
and, either
•
At least one component received by the infected recipient was donated by a donor who had evidence of the same transmissible infection,
or
•
At least one component received by the infected recipient was shown to contain the agent of infection.
Confirmed bacterial infections, by year of transfusion and type of unit transfused (Scotland included from 10/98)