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Laboratory errors in transfusion: Learning for the laboratory

Anne Lockhart, IBMS representative, and Victoria Tuckley from the Serious Hazards of Transfusion (SHOT) scheme explain their latest annual report.

 

The latest SHOT report acknowledges that 2020 has been an extraordinary year for the NHS, which has seen unprecedented pressures placed on both the staff and the service. The total number of reports included in the analysis for 2020 was 3214, compared with 3397 in 2019. The breakdown of all reports analysed and included in the annual SHOT report is available at shotuk.org

SHOT data from 2020 show that while transfusions are generally safe in the UK, there are areas for concern where actions are urgently needed. There has been a steep increase in transfusion-related deaths reported in 2020 – 39 reported in 2020 (17 in 2019). There has been a sharp increase in deaths due to delay, 12 in 2020 (two in 2019). The risk of death related to transfusion in the UK is one in 53,193 and the risk of serious harm is one in 15,142 components issued. 


Key recommendations

  • Transfusion delays, particularly in major haemorrhage and major trauma situations, must be prevented. Delays in provision and administration of blood components including delays in anticoagulant reversal, particularly in patients with intracranial haemorrhage, can result in death, or serious sequelae. Every minute counts in these situations.
  • Effective and reliable transfusion information technology systems should be implemented to reduce the risk of errors at all steps in the transfusion pathway, provided they are configured and used correctly.

Please click here to read the full article.

Image credit | iStock

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