Lm. Williamson et al., Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports, BR MED J, 319(7201), 1999, pp. 16-19
Citations number
17
Categorie Soggetti
General & Internal Medicine","Medical Research General Topics
Objective To receive and collate reports of death or major complications of
transfusion of blood or components.
Design Haematologists were invited confidentially to report deaths and majo
r complications after blood transfusion during October 1996 to September 19
98. S
etting Hospitals in United Kingdom and Ireland.
Subjects Patients who died or experienced serious complications, as defined
below; associated with transfusion of red cells, platelets, fresh frozen p
lasma or cryoprecipitate.
Main outcome measures Death, "wrong" blood transfused to patient acute and
delayed transfusion reactions, transfusion related acute lung injury, trans
fusion associated graft versus host disease, post-transfusion purpura, and
infection transmitted by transfusion. Circumstances relating to these cases
and relative frequency of complications.
Results Over 24 months, 366 cases were reported of which 191 (52%) were "wr
ong blood to patient" episodes. Analysis of these revealed multiple errors
of identification, often beginning when blood was collected from the blood
bank. There were 22 deaths from all causes, including three from ABO incomp
atibility. There were 12 infections: four bacterial (one fatal), seven vira
l, and one fatal case of malaria. During die second 12 months, 164/424 hosp
itals (39%) submitted a "nil to report" return.
Conclusions Transfusion is now extremely safe, but vigilance is needed to e
nsure correct identification of blood and patient Staff education should in
clude an awareness of ABO incompatibility and bacterial contamination as ca
uses of life threatening reactions to blood.