(精选)Cases from the 2009 SHOT Report教学课件.ppt

Cases from the 2009 SHOT Report;Poor decision making / lack of knowledge Slide 3 Failure of checking procedures Slide 18 Sampling / result errors Slide 23 Handling / storage errors Slide 32 Problems with collection Slide 37 Problems with patient ID Slide 43 Laboratory errors Slide 49 Problems with IT Slide 59 Special requirements Slide 69 Anti-D Slide 79 Acute Transfusion Reactions Slide 92 Haemolytic Transfusion Reactions Slide 100 TRALI Slide 113 TACO Slide 117 TAD Slide 127 Autologous Transfusion Slide 132;Poor decision making / lack of understanding;Home platelet transfusion administered without proper protocol or documentation Two units of apheresis platelets were released from the hospital transfusion laboratory on the instruction of the haematology consultant for a colleague to administer to her mother at home. There was no hospital policy for this: no patient ID or compatibility paperwork was completed, nor were any observations documented ;Lack of understanding and training leads to incorrect component selection A newly qualified nurse was sent to collect platelets for a patient going to theatre. The nurse had been booked onto the Trusts competency-assessed blood transfusion training but had been withdrawn at the last minute because of staffing levels. The nurse did not know what platelets looked like and was not aware that they were not stored in the fridge. After searching in the fridge, the nurse selected red blood cells for this patient. Red blood cells had not been prescribed but were available for use in theatre if required. The nurse returned to the clinical area, performed a compatibility check with a more senior nurse and commenced the transfusion. The error was not detected at this point because the ward was extremely busy and they were the only 2 qualified nurses on duty. The error was detected when the transfusion laboratory phoned the ward to remind them that the pl