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Cases from the 2008 SHOT Report

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1Cases from the 2008 SHOT Report. You 40delivered them to the ITU. The laboratory
are free to use these examples in your were not aware that the blood had been
teaching material or other presentations, removed. The patient received 1 unit of
but please do not alter the details as the blood before transfer, and a further 2
copyright to this material belongs to units during transit. On arrival, the
SHOT. They have been loosely categorised, remaining unit was found to be frozen. The
but some cases may be appropriate to patient suffered no ill effects.
illustrate more than one type of error. 41Red cell unit returned to stock
2Poor decision making / lack of despite being out of controlled storage
understanding Slide 4 Failure of checking for over one hour. 6 units of red cells
procedures Slide 15 Sampling / result were issued to theatre, where 3 were
errors Slide 23 Handling / storage errors transfused. The remaining 3 units were
Slide 34 Problems with collection Slide 43 placed in the theatre satellite blood
Problems with patient ID Slide 46 refrigerator and later returned unused to
Laboratory errors Slide 51 Failure to the hospital transfusion laboratory.
follow guidelines Slide 67 Special Subsequently, 1 unit was issued and
requirements Slide 69 Anti-D Slide 75. transfused to another patient. A
3Poor decision making / lack of retrospective check revealed that the
understanding. re-issued unit had been out of controlled
4Lack of recognition of paediatric storage for more than 1 hour. The
emergency units A neonate required recipient showed no ill effects. The
emergency transfusion and 20ml was transfusion laboratory now quarantines all
administered from an adult unit of group O blood component returns from satellite
RhD negative red cells removed from the fridges to confirm that the cold chain has
blood bank by a registered midwife who had been maintained before re-issue.
not received transfusion training. The 42Undue responsibility placed with
unit was not labelled for emergency use, porter, compounded by ignoring the
but was allocated for an adult patient on electronic tracking system A unit of blood
the maternity unit. The blood was not was collected from the blood bank at 1715.
signed out of the issue fridge and the The patient was not cannulated, and the
bedside check was not done. The blood doctor was unable to achieve access
issue fridge was stocked with 2 emergency despite several attempts. The porter
group O RhD negative paedipacks, which returned the blood to the issue
were not used. The baby died the same day, refrigerator at 2020, but did not inform
unrelated to the transfusion. the duty BMS that the unit had been out of
5Red cells administered instead of controlled storage for more than 3 hours.
platelets A unit of platelets was A warning from the electronic blood
prescribed for administration overnight, tracking system was ignored, and the unit
with a further unit of red cells to be was replaced with the rest of the
given in the morning. Although the staff allocated blood. The same unit was
nurse believed she had given a unit of re-taken at 2300, and the electronic blood
platelets, she had collected and tracking warning alert was again ignored.
transfused a unit of red cells, The unit was administered to the patient
administering the component over 50 at 2330, more than 6 hours after initial
minutes as per the platelet prescription. removal from controlled storage.
The prescription form was completed with 43Problems with collection.
confirmation of bedside checks. When 44Incorrect documentation used to
questioned, the nurse stated she did not collect red cells from issue refrigerator
know the difference between a bag of red An anaesthetist asked an ODP to collect 2
cells and a bag of platelets. units of blood crossmatched for a patient
6FFP administered instead of platelets in theatre. The ODP filled out a ‘Blood
Red cells, platelets and FFP were ordered Collection Form’ with details from a
although there was no clinical indication wristband left in the anaesthetic room,
for FFP written in the notes. The patient assuming that this wristband was from the
was prescribed platelets but FFP was patient in theatre. In fact the wristband
collected in error from the transfusion had been removed from a patient on the
laboratory by a porter and administered to previous list. The ODP gave the form to a
the patient instead. The error was not theatre support worker who correctly
realised during the 2-person bedside collected the units of blood for the
check. It only came to light when the patient named on the form. The
transfusion laboratory contacted the ward anaesthetist checked the blood against the
to ask why the platelets had not been accompanying compatibility report only and
used. did not check the patient ID against the
7FFP administered instead of platelets patient’s wristband. The patient was group
FFP, red cells and platelets were O RhD positive, and the unit administered
requested for an 11-day old patient with was group O RhD negative.
sepsis. Platelets were prescribed by the 45Incorrect units collected in place of
doctor, but a registered nurse mistakenly emergency group O RhD negative blood A
collected FFP from the laboratory patient was rushed to maternity theatres
refrigerator. The nurse was reported as for a Caesarean Section as she was
looking for a non-cellular component and starting to haemorrhage. The anaesthetist
seeing the FFP in the refrigerator, requested emergency group O RhD negative
thought this was platelets. The nurse blood. A midwife, who had received
signed in the register against the transfusion training, went to the
platelets, even though the donation number maternity theatre’s satellite blood
was different. The unit of FFP was refrigerator and collected two units of
transfused on the ward following checks by blood from the top drawer without any
2 registered nurses, thinking that this checks, assuming that it was the emergency
component was platelets. The error was blood. The two units were given rapidly.
noticed the next day by a BMS when The anaesthetist commented that the blood
platelets for the patient were found in was group O RhD positive, but as the
the platelet agitator in the laboratory. patient was group A RhD positive, the
8Platelets administered without a anaesthetist was happy it was compatible.
prescription Platelets had been ordered it was only when they took it down that
for an 11-year old child for they realised the blood was allocated to a
administration the following day, pending different patient, and was not the
a final decision (and prescription) on the emergency blood at all.
ward round. Two units of red cells had 46Problems with patient ID.
already been transfused, but the porter 47One patient – two wristbands A 69-year
collected the platelets too. The platelets old male patient was in ITU unconscious
were given by a registered nurse without a following major surgery. The patient had a
prescription. wristband on each wrist, one of which
9Lack of communication between shifts contained details for another patient. The
in SCBU results in baby being transfused correct bedside checking procedure was
twice A 2-month old premature baby had a completed at the bedside, but the patient
haemoglobin of 9.9 g/dl, requiring top-up, ID was taken from the wrong identification
and the team on duty that day administered label on his wrist. The patient, who was
60ml of red cells. Three days later, group A RhD negative, received a unit of
another team on the unit noticed the same group O RhD positive red cells intended
Hb result, made a decision to transfuse for another patient.
and gave a further 70 ml red cells. There 48Dual registration results in
was no indication on the treatment chart misgrouping of a massively transfused
that the patient had been transfused, the neonate A very sick 2-day old neonate with
prescription chart had been filed in the hydrops foetalis grouped as B RhD
wrong place, and notes were not checked positive, and was given large volumes of
for evidence of previous transfusions. group O RhD negative blood in the neonatal
10Inadequate management of acute period. A second sample was taken and
bleeding associated with high INR on details entered into the neonatal
warfarin An elderly woman on warfarin for department computer system, which
AF was admitted with a PR bleed. She was interfaced with the main hospital computer
found to have Hb of 6.8 g/dl and INR of system. However, the previous record
7.2. She was given vitamin K 2 mg IV and 3 number was not retrieved, and a new
units of FFP were requested. All 3 units hospital number was created by the
of FFP were taken at the same time and neonatal system. The second sample grouped
administered over 3 hours. Soon after as O RhD positive, and the neonate
completion of the third unit the patient subsequently received group O FFP and
developed an itchy erythematous rash and platelets. Due to the 2 hospital numbers,
was given IV chlorpheniramine and there was no record of previous
hydrocortisone. Six hours later the transfusions on the second sample, and the
patient was found collapsed and error was spotted when someone queried why
resuscitation was unsuccessful. Postmortem they were transfusing O RhD positive
examination showed fresh blood in the components when they had previously
bowel and cause of death was given as transfused O RhD negative components.
haemorrhage from large bowel. In spite of There was no haemolytic reaction recorded.
blood results and persistent hypotension, The patient was extremely sick and later
this patient received no intravenous died of other complications of hydrops
therapy apart from the FFP, and no blood foetalis.
transfusion was given, though 4 units had 49Wrongly labelled unit transfused
been crossmatched. despite original error having been
11Over-estimation of blood loss from GI detected and corrected When the patient
bleeding leads to massive overtransfusion was admitted, his DOB had been incorrectly
An elderly inpatient had a coffee ground entered on the Patient Information
vomit and some melaena. IV fluids were Management System. He was prescribed FFP,
administered and an FBC showed as Hb of and during the pre-transfusion check he
14.3 g/dl. Her Hb the previous day had mentioned that his DOB was incorrectly
been 14.7 g/dl. Observations were recorded. The FFP was returned to the
initially stable, but her BP suddenly laboratory. The patient was then correctly
dropped and 2 units of red cells were re-admitted onto the PIMS, and the FFP was
transfused. Twenty minutes later, after re-ordered. Unfortunately, the porter
another haematemesis, a further 2 units of collected the incorrectly labelled units
red cells were transfused. No repeat FBC of FFP which were still on the bench in
samples were taken due to poor venous the laboratory. The nurses assumed that
access. Two hours later, the BP was the FFP was labelled correctly and did not
stable, and a further 2 units were repeat the bedside administration check
transfused. The Hb later that day was 16.6 before transfusing it. The patient was not
g/dl, rising to 18.3 g/dl that night, and wearing an ID band during the transfusion
20.8 g/dl the following afternoon. The episode, as the old incorrect one had been
patient died on the evening of the removed and the new correct one had been
following day. generated but not attached.
12Overestimation of blood loss from 50A pointless ‘check’ between two
acute GI bleed A patient was admitted to incorrect documents generated by the same
the ED with a GI bleed. Hb on admission computer system A clerical error occurred
was 12.1 g/dl. 2 units of emergency blood in the laboratory while inputting the unit
were given, followed by 6 units of number for the (laboratory generated)
crossmatched blood over the next 12 hours. prescription sheet and compatibility
The FBC was not re-checked until all 8 label. The details on the original request
units had been transfused, by which time form were correct. The nurses
the Hb was 18.5 g/dl. administering the component failed to
13Overtransfusion and subsequent carry out a patient identification
venesection of a 1-year old under shared procedure; they checked the prescription
care A small 1-year old undergoing shared form against the compatibility label, both
care attended her DGH for a top-up of which contained the incorrect hospital
transfusion of 2 paediatric units of red number. They did not check the
cells as recommended by the tertiary documentation with patient ID, as the
referral centre. This was written on the patient was not wearing a wristband.
prescription sheet as ‘2 units’ and no 51Laboratory errors.
volume specified. As she had not 52Electronic records and automation
previously been transfused at the DGH, and highlight historical error At
being over 1 year old, the laboratory authorisation of a blood grouping result,
supplied adult red cell packs. Four days the pathology computer flagged a mismatch
post transfusion, her Hb was excessively with historical data, which stated that
high and the error was discovered. Her Hb the patient was AB RhD positive. The
continued to rise and necessitated current sample grouped as O RhD positive,
venesection of the patient. and a repeat sample also proved to be O
14Confusion over correct dosage of RhD positive. The historical search
cryoprecipitate A patient was administered identified that 2 units of AB RhD positive
10 packs of pooled cryoprecipitate rather red cells had been transfused to this
than the recommended 2 packs. The order patient a year earlier. Further
for the blood component had been placed by investigation revealed that two samples
a consultant haematologist using old received at the same time a year earlier
single pack units rather than pooled had been transposed in the laboratory,
packs, leading to confusion in the resulting in the transfusion of 2 units of
laboratory. AB RhD positive red cells to the O RhD
15Failure of checking procedures. positive patient, and also the transfusion
16Lack of understanding of what a of 3 units of O RhD positive red cells to
bedside check involves, and why A 67-year an AB RhD positive patient. Neither
old female patient in a side room was patient was reported as suffering any ill
prescribed a transfusion. A trained effects following transfusion of
housekeeper took the correct patient ABO-incompatible units.
documentation to the issue fridge, but 53When IT fails, electronic issue cannot
collected a unit of blood for a different be used A 19-year old female was admitted
patient with the same first and last name. as an emergency with head trauma. The
The unit was checked outside the side sample was tested using routine automation
room, against the compatibility statement, but the interface froze and the result was
by two nurses. The transfusion record was entered manually onto the laboratory
completed by both nurses indicating that computer system (LIMS). Results from the
all checks had been completed. One nurse wrong patient were entered. The blood was
then entered the room and administered the then allocated to the patient using
blood without a bedside ID check. The electronic issue. 4 units of group A RhD
patient was group O RhD positive and positive red cells were transfused to this
received a unit of A RhD positive red patient, who was actually O RhD positive.
cells. The already severely ill patient The error was identified when the patient
developed respiratory problems and died developed symptoms of a HTR with red urine
later that day, though there was no record and falling haemoglobin. Fortunately, she
of haemolysis. made a full recovery from her
17No patient ID check when administering ABO-incompatible transfusion.
group-specific units A 77-year old man 54Competency assessment on blood group
with a ruptured aortic aneurysm was anomalies must form part of training A
admitted via ED straight to theatre for grouping discrepancy was highlighted on
emergency surgery. An anaesthetist the automated group of a 74-year old
collected what he thought was emergency patient requiring transfusion for anaemia.
group O RhD negative blood from the The forward group was A, but there was no
theatre fridge, which was in fact group B reaction with the B cells in the reverse
RhD positive blood issued for a specific group. The BMS rechecked the group and
patient. A second anaesthetist thought that there was a weak reaction
administered the blood without any ID with anti-B, and interpreted the group as
checks. The transfusion laboratory then AB. However, as there was some
issued group specific blood for the uncertainty, the BMS selected group A red
patient, who was group A RhD positive. A cells for crossmatch and transfusion.
consultant anaesthetist notice the Further testing of the sample by
discrepancy in blood groups and laboratory staff the following day
highlighted the error made earlier. There confirmed that the group was A. It was
was no evidence of a transfusion reaction felt that inexperience led to the mistake.
or haemolysis, and the patient died as a 55The difficulties encountered with
result of his ruptured aneurysm. cases of AIHA A 93-year old female with
18Acute haemolytic reaction in a frail AIHA was transfused 4 units of group A RhD
elderly man administered ABO-incompatible positive blood rather than group O RhD
red cells A 91-year old male patient who positive blood because of a laboratory
had sustained a head injury and error in result interpretation. The
intracranial bleed was prescribed a patient sample had been tested overnight,
transfusion, administered after midnight. but the results were held for
The incorrect unit of red cells was authorisation as the DAT was 4+ and the
collected by an untrained registered antibody screen was 3+. The next morning
nurse. Pre-transfusion checks were the card was incorrectly interpreted as
conducted by 2 registered nurses, against group A RhD positive. The patient was
the compatibility statement, which was reported (by telephone) by a NHSBT RCI
signed, timed and dated. The patient was reference laboratory as having
wearing a wristband, but this was not used autoantibodies and anti-E. Four units of A
in the checking process. The patient, who RhD positive, E(-), K(-) units were
was group O RhD positive, received group B crossmatched for the patient. All units
RhD positive red cells. After 100ml of the were incompatible, as was the patient’s
transfusion, he became agitated and auto, but were issued for transfusion. The
pyrexial and the transfusion was error was noticed when the paper copy of
discontinued. He died 9 days later and the the RCI report arrived. No adverse effects
coroner concluded that death was due to were noted that could be attributed to the
causes other than the transfusion. transfusion.
19Lack of positive ID check at 56RhD types must not be assigned on one
collection and administration A 92-year weak reaction A patient initially gave a
old male patient with a GI haemorrhage was weak reaction with anti-D reagent and was
prescribed a blood transfusion in the ED. reported as RhD positive without further
Correct documentation was taken to collect investigation. Two units of group O RhD
the units, but was not used to identify positive red cells were transfused and all
the unit at the issue refrigerator. The subsequent samples grouped as strongly RhD
incorrect unit was collected and was positive. Over a three week period, 14 O
checked by 2 staff nurses against RhD positive red cells and 6 O RhD
accompanying paperwork, but not checked positive platelets were transfused.
against any other patient ID as the Several months later the patient presented
patient was not wearing a wristband and as O RhD negative with anti-D. Genotyping
was unable to participate in the checks at BGRL confirmed the patients as RhD
himself. The patient was group B RhD negative.
positive and the unit was group A RhD 57Take due care when selecting blood for
positive. After 50ml of the transfusion special patient groups Two units of blood
the patient developed an acute reaction were ordered from NHSBT; 1 unit for a
and the transfusion was stopped. He neonatal exchange transfusion and the
developed haemolysis but recovered fully. other a phenotyped unit for a child with
20Lack of ID checks at patient’s side A thalassaemia major. The duty BMS issued
haematology patient required a second unit the irradiated unit, specified for
of red cells, so the registered nurse exchange transfusion, to the thalassaemia
looking after the patient co-opted a major patient, and the non-irradiated
second registered nurse to perform the phenotyped unit for the exchange
patient ID check. All the documentation transfusion. The error was discovered when
was completed and signed by both nurses at the paediatrician realised that they did
the nurses’ station. The first nurse then not have enough blood to complete the
took the unit into the 6-bedded bay alone, exchange transfusion. The child with
and administered the blood to the patient thalassaemia major did not actually
opposite the one for whom it was intended, receive any blood as the mistake had been
without a bedside ID check. An A RhD identified prior to commencement of her
negative patient was thus transfused with transfusion.
a unit of group O RhD positive red cells. 58Take due care when selecting platelets
No transfusion observations were for special cases NHSBT delivered 2 ATDs
conducted. Both nurses had received of platelets for 2 different patients. The
transfusion training within the previous BMS transposed the units in the laboratory
12 months. and issued a pack of HLA-matched platelets
21No patient ID check made in emergency ordered for a haematology patient, to the
situation when box of blood for two other patient, who was bleeding.
patients delivered to ED Blood for two Fortuitously, the platelets were
patients was sent in the same box from the ABO-compatible.
transfusion laboratory to the ED. A 59Is causing less distress to a
37-year old male trauma patient required paediatric patient a valid reason for
urgent transfusion and blood for a using less safe practice ? While a 9-month
different patient was removed from the box old male patient was in the anaesthetic
and administered by an anaesthetist, room prior to surgery, blood was taken for
without checking the details of the a Group & Save. This is the usual
patient in any way. Each member of staff procedure to avoid distressing younger
thought the other had performed the ID children prior to elective surgery. A
checks. The patient, who was group O RhD rapid manual group was performed in the
negative, received a unit of group O RhD laboratory, interpreted (incorrectly) and
positive red cells. He died due to his authorised by a BMS as group O RhD
major trauma. positive with a negative antibody screen.
22Bedside check omitted in favour of a Two units of O RhD positive red cells were
‘treatment room check’ Forms and issued and transfused. A repeat sample
documentation for a transfusion were from the patient, tested by the routine
completed and signed by two registered automated method in the laboratory, showed
nurses in the treatment room. One of the that the patient was actually group O RhD
nurses then took the unit and connected it negative.
to a different patient, also awaiting 60IT warning flags are only helpful
transfusion, without a bedside patient ID prompts – staff must understand the
check. A little later, blood was being reasons behind protocols A patient had
prepared for transfusion to this patient, been transfused on 28th Jan. According to
who was found to already have a local policy the sample was unsuitable for
transfusion running, so the error was further use from 30th Jan. Despite this,
discovered. Both patients were group B RhD the sample was used to serologically
positive. crossmatch blood on 3rd Feb, the computer
23Sampling / Results errors. indicating that electronic issue was ‘not
24Doctor’s phlebotomy error results in 2 available’. The 2 members of staff
unit ABO-incompatible transfusion An involved in the incident were senior
elderly patient was bled and grouped as B members of the haematology department
RhD positive, and transfused with 2 units working in blood transfusion ‘out of
of B RhD positive red cells for anaemia hours’. It was clear that they did not
(cause not given). This patient had been understand the reason for the computer
bled by a doctor during normal working indicating that electronic issue was
hours. A subsequent sample that grouped as unavailable. The blood was transfused
A RhD positive was rechecked and proved to uneventfully.
be the correct blood group. The wrong 61The importance of antibody history A
patient had been bled when the original patient arrived in the ED with a GI bleed
sample was taken. Fortunately the patient and 2 units of ‘flying squad’ O RhD
did not suffer any ill effects from 2 negative blood were used. A blood group,
units of ABO-incompatible blood. antibody screen and retrospective
25Phlebotomists’ patient ID error crossmatch on the transfused units was
results in 3 unit ABO-incompatible performed. The antibody screen and
transfusion An elderly gentleman required crossmatch were negative, but the on-call
an amputation for gangrene and was grouped BMS noticed that the patient was known to
as B RhD positive. 3 units of B RhD have anti-Jka and anti-f. The ward phoned
positive red cells were transfused in the later to ask for more blood to be
perioperative period. A post-operative crossmatched. The BMS crossmatched
sample taken a few days later prior to a unselected units as the current antibody
laparotomy grouped as O RhD positive. The screen was negative, and all units were
patient had in fact suffered some crossmatch-compatible. The patient
respiratory problems, further anaemia and received 3 units of A RhD positive blood.
hyperbilirubinaemia following his original The incident was investigated the
transfusion, but these had been attributed following day and all five transfused
to his multiple co-morbidities and units were found to be Jk(a+). The flying
possible fluid overload. The patient squad units and 2 of the A RhD positive
eventually died of complications unrelated units were f(+). The patient died from the
to his ABO-incompatible transfusion. The underlying clinical condition.
incorrect sample had been taken from the 62The need for complete documentation
wrong patient by a phlebotomist. Six units of blood were issued using
26Acute HTR from ABO-incompatible emergency procedures for a patient
transfusion comes to light 11 years later admitted with a GI bleed. Full
The patient, an elderly male, grouped as O compatibility testing was completed
RhD negative, which was discrepant with retrospectively. The antibody screen was
the original blood grouping result held in positive, and 1/6 units was incompatible.
the computer system from 11 years earlier, The BMS immediately contacted the clinical
when he was grouped as A RhD negative. area to recall the units, but 4, including
Further investigation revealed that 11 the incompatible unit, had already been
years earlier he had received 2 units of A transfused. Further investigation revealed
RhD negative red cells resulting in a that the patient was already known to have
haemolytic episode with renal failure anti-C+D+E, but the critical notes in the
requiring dialysis. A full recovery was laboratory had not been updated with this
made, and it was not clear from the information. There was no adverse reaction
records whether the transfusion was reported.
implicated at the time. The patient is now 63The danger of manual transcription of
established as group O RhD negative. results when the computer is ‘down’
27Doctor’s phlebotomy error in emergency Following an urgent request for blood for
situation A middle-aged man with hepatic a patient with cranial trauma going to
failure and perforated ulcer grouped as A surgery, the on-call BMS manually
RhD positive. 6 units of red cells were transcribed incorrect blood grouping
crossmatched, 10 units of FFP and 2 units results when the laboratory computer
of platelets were issued, all A RhD interface ‘froze’ Two units of group A red
positive. The FFP and platelets were cells were transfused to a group O patient
given, but fortunately the red cells were who subsequently developed red urine and
not, as subsequent samples revealed that falling Hb, but otherwise made a complete
the patient was in fact group O RhD recovery.
positive and that the doctor had bled the 64Multiple errors lead to transfusion of
wrong patient. The patient suffered no red cells of the wrong ABO group post BMT
reaction. A group A RhD positive patient received a
28Incorrect Hb level and group following bone marrow transplant from a group O RhD
patient ID error A middle-aged gentleman positive donor. Despite appropriate prior
with brain metastases and seizures had notification by the clinical team, the
samples taken for a repeat haemoglobin, laboratory computer system was not updated
which revealed that his Hb had dropped to warn of the new requirement. 6 units of
from 13.7 to 8.9 g/dl. The patient was group A RhD positive red cells were issued
crossmatched using a group & save during routine working hours over the next
sample taken at the same time as the Hb 2 months. Following receipt of a further
sample and transfused 2 units of O RhD notification from the clinical area, the
positive red cells. This resulted in a LIMS was updated. However, because of
post-transfusion haemoglobin level of 15.3 failure to consult the historical record,
g/dl. A historical blood group (possibly a further 4 units of A RhD positive red
from another hospital) was subsequently cells were issued over the next 3 months
discovered for this patient, who turned before the error was noticed. The patient
out to be really AB RhD positive. It was experienced no ill effects.
clear that the wrong patient had been 65Cryoprecipitate mistakenly issued
bled, as both the Hb result and blood instead of FFP An urgent request for 2
group were incorrect. Fortunately, the units of FFP was received at a time when
patient suffered no reaction to the the LIMS was ‘down’. The lone-working
transfusion of O RhD positive red cells. on-call BMS erroneously selected and
29Transfusion and multiple issued 2 pooled packs of cryoprecipitate.
investigations based on a ‘drip arm’ The LIMS normally reconciles the component
haemoglobin A patient was admitted with selected with the request at the point of
dizziness and collapse and a history of issue, and the laboratory SOP states that
CVA. The patient’s Hb was 11.4 g/dl on 2 members of staff should check each
admission, but had apparently dropped to issue. However, only 1 BMS is ever
6.9 g/dl the following day. The FBC was available during the out of hours period.
not repeated and the patient was 66Computer rule leads to transfusion of
transfused 2 units of red cells even non-irradiated and CMV-screened platelets
though there was no evidence of blood A group A RhD negative male patient with
loss. In addition, various investigations non-Hodgkin’s lymphoma required irradiated
were requested post transfusion, including and CMV negative components. This
abdominal ultrasound and haemolysis requirement was recorded correctly on the
screen. An inpatient referral was made to LIMS. Appropriate platelets were ordered
a consultant haematologist, who assessed from the local blood centre. Due to
the patient and questioned the validity of limited availability of group A CMV
the Hb result. A repeat sample showed an negative donations, the blood centre
Hb of 13.1 g/dl, and further investigation issued a group B RhD positive adult
revealed that the second sample had been therapeutic dose (this is second choice
taken from the same arm as the drip. after group-specific according to national
30Transfusion based on a year-old guidelines). However, the hospital LIMS
haemoglobin result Two units of blood were had a built in rule that prevented issue
requested for an orthopaedic trauma case of a different ABO group to the patient.
because of low pre-op haemoglobin of 9.7 The on-call BMS was ‘distracted’ by this
g/dl. The blood was provided and occurrence and selected an alternative
transfused. A phone call to the laboratory pack of group A non-irradiated,
to check the pre-op Hb result and non-CMV-screened platelets, which were
coagulation screen alerted the staff to subsequently transfused.
the fact that the samples sent had been 67Failure to follow guidelines.
clotted and therefore could not be 68A hydropic baby is transfused
analysed. The result used to request the S-positive units, though mother had
transfusion had in fact been taken on anti-S. It was not checked antenatally. A
exactly the same date, but one year baby girl was born at 37 weeks gestation
earlier. The post-operative Hb was 13.9 following emergency CS. The child was
g/dl. pale, floppy and hydropic with a
31Spurious pancytopenia results in haemoglobin of 2 g/dl. The baby was group
unnecessary hospital admission and AB RhD positive, the mother group B RhD
prophylactic platelet transfusion A positive and the father group A RhD
patient was bled for an FBC by a GP positive. Emergency group O RhD negative
practice nurse after presenting with blood was given (140ml). Laboratory tests
arthralgia and a rash. The results showed showed the baby was DAT positive. The
a pancytopenia with Hb 9.2 g/dl, WBC, 0.4 mother’s plasma contained anti-S at a
x 10^9/l and platelets of 7 x 10^9/l, with titre of 1/8 at delivery, and both father
no evidence of a clot in the sample. The and baby were S-positive. The anti-S had
patient, who appeared well, was admitted been undetectable at booking, and the
to a medical ward out of hours where the mother was not retested at 28 weeks, as
admitting junior doctor telephoned the she was RhD positive. The emergency O RhD
duty consultant haematologist who advised negative blood used was found to be
isolation because of the neutropenia and a S-positive, and there was a poor increment
platelet transfusion. The patient was in Hb following transfusion. The baby
reviewed by the consultant haematologist received an exchange transfusion of
the next day and was found to be well, S-negative units, and the hospital now
apyrexial with no purpura or petechiae, complies with national antenatal
and a repeat FBC showed Hb 13.4 g/dl, WBC guidelines to test all patients at 28
8.2 x 10^9/l and platelets of 351 x weeks, regardless of RhD type.
10^9/l. 69Special requirements.
32Short sample gives spurious result 70Requestor does not inform the
leading to 3-unit transfusion A woman transfusion laboratory that patient is
requesting a termination of pregnancy had pregnant A patient who was 22 weeks
samples for FBC and Group & Save taken pregnant was admitted via the ED with
by a phlebotomist. A small sample was status epilepticus and transferred to ITU.
taken into a paediatric bottle because of The Hb was 6.7 g/dl and 2 units of red
poor venous access. The Hb was reported as cells were requested and transfused. No
6.3 g/dl and the woman was admitted that diagnosis was given on the request form
night for pre-op transfusion of 3 units of despite boxes being available to tick (ie
blood. No repeat FBC was taken before Pregnant? Yes/No/Unsure). The following
transfusion, and no investigations into day it was discovered by transfusion
the cause of anaemia were requested. Two laboratory staff that the patient was
days later the haemoglobin result was 15.6 pregnant, and the units were investigated.
g/dl, suggesting that the previous FBC had One had by chance been CMV negative, but
been erroneous and that transfusion had the other had not.
been unnecessary. 71‘Sickle cell disease’ not stated on
33Unnecessary transfusion based on request for red cells A patient was
obviously erroneous result A patient was admitted with anaemia and assigned a new
admitted to the ED and samples sent for hospital number as a new PAS system had
FBC and crossmatch. A Hb result of 2.7 recently been installed. No previous
g/dl was telephoned, and the BMS advised transfusion was mentioned on the request,
repeating the sample as the result was even though the patient had a previous
suspect. However, this was not done, and record on another number. The request form
the patient was immediately transfused stated only ‘anaemia’ as the indication
with 2 units of red cells. On admission to for transfusion; although the patient
the ward a further FBC was taken, showing suffered from sickle cell disease, the
a Hb of 13.7 g/dl. However 4 further units diagnosis was not given, and therefore the
had been prescribed and were given, laboratory staff were not prompted to look
resulting in a post-transfusion Hb of 18.8 for any previous transfusion history on an
g/dl. older hospital number. The patient was
34Handling / storage errors. transfused non-phenotyped blood.
35Transfusion continued despite leak 72Transplant centre did not inform
from port exposing contents to referring hospital of ABO-mismatched
contamination A patient was transfused transplant A patient was referred to
with 2 units of red cells and the nurse another trust for a bone marrow
giving the units noticed that blood was transplant. Post-transplant no details of
leaking from the port into which the the donor group were sent to the referring
giving set was inserted. She continued the trust, so consequently the blood
transfusion rather than stopping it, and transfusion laboratory there were unaware
informed the transfusion laboratory after that the patient had received a major
the event. The bags were returned to the mismatch marrow (the patient was O RhD
local Blood Establishment laboratory for positive and received a group A RhD
investigation but no defect was found. The positive transplant) and now required FFP
patient suffered no ill effects. and platelets of a different group. The
36Lack of knowledge leads to transplant team at the centre was
inappropriate concerns and non-compliance contacted, and faxed through a copy of the
with basic protocols A unit of blood was transplant protocol. The original
removed from the blood bank by an distribution list on the protocol document
auxiliary nurse, who did not see that it did not include the referring hospital.
had expired at midnight the previous day. 73Laboratory misses fact that there are
The 2 registered nurses who undertook the TWO special requirements A patient
pre-administration check were worried that required both CMV negative and irradiated
the donor and recipient groups were not components, and a request was made for 2
the same, even though the accompanying units of red cells. CMV negative, but not
documentation clearly stated that the irradiated units were issued by the
blood groups were different but laboratory and administered to the
compatible. The nurses thought that they patient.
had completed the checks when they were 74BMS omits to issue CMV negative
distracted by the blood group ‘problem’ components for pregnant woman with sickle
and telephoned the laboratory for advice. cell disease A patient with sickle cell
They then administered the blood without disease was pregnant, on a high dependency
checking the expiry date. The patient ward. Her haemoglobin was 5 g/dl, and an
suffered no ill effects, and the error was urgent request was made for 4 units of red
discovered by the same nurses when they cells. Phenotyped units were requested due
prepared to administer the next unit of to the sickle cell disease, but the BMS
blood. forgot to issue CMV negative units. The
37In absence of security normally patient received all 4 units overnight,
provided by an electronic system, basic the error being discovered when more units
checks are omitted A nurse was sent to were requested the following day to cover
collect 1 unit of red cells from the issue a caesarean section.
fridge, but the electronic blood tracking 75Anti-D.
system was ‘down’. The BMS on duty used 76Manual transcription error in the
the manual override to open the laboratory results in omission of anti-D
refrigerator and handed the unit to the and subsequent D-sensitisation A pregnant
nurse. The expiry date was not checked patient had bloods taken at booking
either by the BMS or the nurse during this clinic. The BMS performing ABO and RhD
process. The pre-transfusion check was grouping manually recorded the result as
performed at the patient’s bedside. The RhD positive instead of RhD negative.
nurse stated that the expiry date had been Consequently, routine antenatal anti-D
checked, but the fact that the unit had prophylaxis was not administered, nor
expired the previous night was not would anti-D have been considered for any
recognised. The patient was transfused potentially sensitising event the patient
with no ill effects and the error became may have suffered. The patient was found
apparent during a refrigerator stock check later in pregnancy to have developed an
later that morning. immune anti-D.
38Slow transfusion due to poor venous 77‘Weak D’ baby recorded as D negative A
access not attended to appropriately in BMS altered a baby’s blood group on the
overnight transfusion A patient was laboratory computer from ‘weak D’ to RhD
prescribed 4 units of red cells for negative in order to facilitate a request
anaemia. A porter collected the 3rd unit for blood made by the clinical area for
at 0100 and it was commenced at 0115. The the baby. Because the baby’s group was now
blood ran slowly, so the cannula was ostensibly RhD negative, the mother never
re-sited and transfusion recommenced at received an injection of anti-D Ig.
0550. The midwife on the day shift tried 78Lack of knowledge of when it is
to flush the cannula to complete appropriate to issue anti-D Two midwives
transfusion, which was documented as separately checked the hospital computer
stopped at 1000, incomplete. The prolonged system, which clearly showed the patient
transfusion time was only noticed when the to be RhD positive, yet still proceeded to
TP was auditing the documentation process. issue anti-D Ig to the patient from a
The unit had been administered over a stock held in the clinical area.
total of 9 hours. 79Junior doctor gives anti-D without
39Overnight transfusion prescribed for 4 knowledge of patient’s blood group
hours not monitored and runs for >10 Following a day case gynaecological
hours A unit of red cells was collected procedure, a FY2 grade doctor prescribed
from the blood bank at 2110. According to and administered anti-D Ig from a clinical
documentation, transfusion was commenced stock to a patient, without a blood
at 2130 by a trained trust bank nurse and grouping report being available in the
an agency nurse, with the prescription for clinical area, and without checking to see
transfusion over four hours. The what the blood group was. The patient was
transfusion was not recorded on a fluid subsequently found to be RhD positive.
balance chart. The bank nurse went home at 80Use of patient notes in an ID check,
2300, and the agency nurse took in place of the patient’s wristband or
responsibility for the patient. Day staff verbal confirmation A midwife collected
took over at 0800, and the unit was still anti-D Ig, and then took it to the wrong
running. The transfusion was eventually patient along with the intended patient’s
stopped at 0830, more than 10 hours after notes. She then proceeded to check
commencement. identification details against the notes
40Undue responsibility placed with rather than with the patient and
porter, and lack of liaison about critical administered the anti-D.
patient transfer A patient in ITU was 81A totally different immunoglobulin
bleeding with associated coagulopathy, given instead of anti-D A vial of Herpes
requiring large volumes of plasma and red Varicella Zoster globulin was issued by
cells. Transfer to another hospital was the transfusion laboratory to the clinical
arranged for specialist treatment, and 4 area included in a supply of 250iu anti-D
units of red cells were to be available bulk stock. The discrepancy was missed at
for the transfer. The porter collected 4 the bedside checking stage, and a midwife
red cells from the blood bank, but packed administered the incorrect globulin in
them in a bag containing ‘dry ice’ and place of the indicated 250iu anti-D Ig.
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