Errors in anti-D immunoglobulin administration: Retrospective analysis of 15 years of reports to the UK confidential haemovigilance scheme
OBJECTIVE: To highlight the errors associated with the use of anti-D immunoglobulin in RhD antigen-negative women, and their resultant clinical impact during and after pregnancy, and to suggest strategies to reduce these errors. DESIGN: Retrospective review of cumulative reporting to the UK confidential haemovigilance scheme, Serious Hazards of Transfusion (SHOT), between 1996 and 2011. SETTING: Obstetric departments in the UK. POPULATION: Mothers who require anti-D immunoglobulin to prevent RhD sensitisation during pregnancy or after birth. METHODS: Hospital transfusion teams reported adverse events to the SHOT database. MAIN OUTCOME MEASURES: Reported number of events and their causes, and morbidity and mortality associated with errors. RESULTS: In 15 years of reporting, SHOT haemovigilance has shown a total of 1211 errors related to the administration of anti-D immunoglobulin, particularly regarding omission or late administration (157/249 or 63% reported in 2011). Anti-D immunoglobulin errors comprised 13.7% (249/1815) of all SHOT reports in 2011. Failure to recognise women who already have RhD sensitisation occurred in 19 cases, and was followed by suboptimal monitoring of the pregnancy. Nine of the infants suffered haemolytic disease of the fetus and newborn (HDFN): one resulted in neonatal death and three required red cell transfusion. CONCLUSIONS: Babies as well as their mothers remain at risk from avoidable errors. More active attention at national and local levels to further education and training, particularly for midwives, is an absolute necessity. We recommend the use of a SHOT-devised anti-D administration flowchart, adapted locally into a checklist, to help reduce errors.
Available from: Paula Bolton-Maggs
- "A key finding from these data is that most errors are late or missed prophylactic doses of anti-D immunoglobulin, putting women at risk. Most of these errors are made by midwives and nurses (Bolton-Maggs et al, 2013b). ‘Near miss’ incidents were collected from 2000/2001. "
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ABSTRACT: The Serious Hazards of Transfusion (SHOT) UK confidential haemovigilance reporting scheme began in 1996. Over the 16 years of reporting, the evidence gathered has prompted changes in transfusion practice from the selection and management of donors to changes in hospital practice, particularly better education and training. However, half or more reports relate to errors in the transfusion process despite the introduction of several measures to improve practice. Transfusion in the UK is very safe: 2·9 million components were issued in 2012, and very few deaths are related to transfusion. The risk of death from transfusion as estimated from SHOT data in 2012 is 1 in 322 580 components issued and for major morbidity, 1 in 21 413 components issued; the risk of transfusion-transmitted infection is much lower. Acute transfusion reactions and transfusion-associated circulatory overload carry the highest risk for morbidity and death. The high rate of participation in SHOT by National Health Service organizations, 99·5%, is encouraging. Despite the very useful information gained about transfusion reactions, the main risks remain human factors. The recommendations on reduction of errors through a 'back to basics' approach from the first annual SHOT report remain absolutely relevant today.
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ABSTRACT: Hemovigilance is an essential part of the transfusion process and is defined as surveillance procedures covering the whole transfusion chain, from collection of blood and its components, intended to collect and assess information on unexpected or undesirable effects resulting from the therapeutic use of labile blood products and to prevent their occurrence or recurrence. The UK surveillance scheme has collected data for 16 years and is a model demonstrating how information on adverse incidents can be used to improve patient safety, influencing the management of donors and improved education and training for the many people involved in the transfusion process.
Available from: Caroline E Overton
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