ITSupport-Casesfromthe2007SHOTReport.pptVIP

Cases from the 2007 SHOT Report;Incompatible transfusion Slide 3 Poor decision making Slide 6 Failure of checking procedures Slide 25 Sampling / result errors Slide 33 Handling / storage errors Slide 42 Problems with collection Slide 52 Problems with patient ID Slide 56 Failure to follow protocol / SOP Slide 60 Special requirements Slide 70 Anti-D Slide 77;Incompatible transfusion;Patient’s mother alerts clinicians to changed ABO group A 6 year old boy who was A D positive had an ABO mismatched SCT from an O D positive donor. One month later he was transfused with A D positive red cells as no information had been communicated to the hospital transfusion laboratory. When group A D positive red cells were again issued the next month the child’s mother informed nursing staff that he should have O D positive blood. There was no adverse reaction. ? ;Two ABO incompatible units transfused resulting in need for red cell exchange transfusion A man with metastatic prostate cancer presented in AE with a Hb of 5.3 g/dl and gastrointestinal bleeding. Two units of blood were collected by a registered nurse from the issue fridge and commenced via two cannulae. The patient became pyrexial with rigors, loin pain and hypotension and 1 hour after starting the transfusion the nurse called the doctor who stopped the transfusion: by this time most of both units was transfused. The doctor found that the red cell units were for a different patient, and that the units were incompatible, the patient being O D positive and the two transfused units B D negative. The patient received immediate supportive case and further advice was sought from the haematology consultant. A red cell exchange of 4 units of correct ABO/D group red cells took place. The patient suffered worsening renal impairment, and was later discharged to a hospice.;Poor decision making / lack of understanding;Worrying lack of comprehension of reasons for standard procedures, and disregard fo