A report by the UK’s blood transfusion watchdog, Serious Hazards of Transfusion (SHOT), has warned of safety risks to patients from an ‘alarming upward trend in errors and harms’ in the preparation and administration of blood transfusions. SHOT’s recently published Annual Report 2022 identified mistakes at all stages of the transfusion process, from collection of the blood sample, laboratory errors, to identifying the correct patient and administering the transfusion, with errors often arising from ‘a willingness to disregard formalised procedures and safety checks in pressured situations’. In many cases, multiple errors contributed to fatal or serious injury to the patient. SHOT expressed concerns that the high number of errors suggests that system level factors (such as workload and workforce pressures) are not being properly addressed and called for urgent action to improve transfusion safety. What is haemovigilance? Haemovigilance helps identify and prevent transfusion-related errors and patient harm, to make blood transfusion more effective and safer for patients. Serious Hazards of Transfusion (SHOT) is an independent, professionally-led haemovigilance scheme, which collects and analyses anonymised information on patient harm from blood transfusions from all healthcare organisations that work with transfusions of blood and blood components in the UK. SHOT makes safety recommendations to UK Blood Services, the Departments of Health in all four UK nations, all relevant professional bodies and hospitals, via its annual reports. How many patients were harmed in 2022 from preventable transfusion errors? In 2022, a total of 3499 reported transfusion errors and incidents were analysed by SHOT, an 11% increase from 2021. A further 52 reports of anti-D immunisation were analysed as part of a separate study. 83% of the reported events were preventable errors which caused harm or were near misses (39%) with the potential to cause harm to patients. Transfusion errors in A&E or ED emergency departments increased for the second year running and have doubled since 2020. Most mistakes (45.5%) occurred on general wards, with 43.2% in routine transfusions and 27.3% emergencies. Laboratory transfusion-related errors increased in 2022, to a total of 431. Lab mistakes, such as testing and selection errors, led to 109 patients receiving transfusion of blood components which did not meet their specific needs. SHOT noted that many of these lab errors caused major morbidity (ill-health or disease) to patients but should have been prevented by staff with basic knowledge. Staff who were apparently up to date with their competency assessments often did not have the basic knowledge needed to complete tasks. Clinical errors occurred at the request step of the transfusion process (63.9%), at collection (16.0%) and during administration (14.6%). Collection errors have doubled over the past five years, suggesting a lack of learning from past mistakes. The most common avoidable errors in 2022 included mistakes in anti-D treatment during and after pregnancy for the prevention of harm to babies from rhesus disease, handling and storage errors, ensuring the patient received the correct blood, delayed reversal by prothrombin complex concentrate (PCC) of blood thinning anti-coagulants in acute cases of serious haemorrhage, circulatory overload, and avoidable, over/under or delayed transfusions. Transfusion delays and lung/respiratory problems from transfusion-associated circulatory overload (TACO) together accounted for 60% of transfusion-related deaths reported in 2022. There were 205 delayed transfusions, accounting for the largest number of transfusion-related deaths in 2022. Poor communication often contributed to delays. SHOT emphasised that patients should not die from bleeding or suffer harm from avoidable delays in transfusion, but delayed recognition of bleeding and delayed transfusion both increase the risk of injury and death. Where a patient has low blood pressure, clinicians should be alert to the possibility that they are suffering from haemorrhage. In 64 cases of major haemorrhage, including obstetric and gastrointestinal bleeds, 41 transfusions were delayed. Major haemorrhage protocols were either not activated promptly or were not followed correctly with a single call to a dedicated telephone line which was then cascaded to all relevant departments. In 8.5% of reported cases, the patient was transfused with a blood component which was either from an incorrect blood group, intended for another patient (whether or not compatible with the recipient), or was different from what was prescribed. These incidents can cause serious or fatal injury to the patient. Nearly 22% of all wrong blood transfusions were due to incorrect patient identification, a basic healthcare process error which SHOT said could not be justified. Two patients died after standard safety checks were neither performed during collection of the blood or later at the bedside pre-administration check. SHOT found that it was only by chance that many more patients had not suffered harm from similar failures. More than half of all under/over transfusion mistakes involved paediatric (child) patients. Incorrect dosage of other types of medicines for children has previously been highlighted by HSIB as a cause for concern. SHOT reiterated these concerns and recommended that healthcare staff who authorise transfusions for children should be properly trained to calculate the correct dose of all components. Febrile, allergic, or hypotensive (low blood pressure) transfusion reactions accounted for 53.5% of cases of major injury. In one severe case, a patient who received a red cell transfusion for iron deficiency anaemia suffered a cardiac arrest and hypoxic brain injury from anaphylaxis. SHOT pointed out that these potentially life-threatening reactions often cannot be predicted or prevented, but when they occurred, their management with steroids and antihistamines was often inappropriate. The watchdog emphasised the need to reduce the risk of transfusion reactions by ensuring that transfusion is only given when clinically indicated, and with the fully informed consent of the patient. Anti-D treatment errors in pregnancy Anti-D treatment is given to mothers with a Rhesus D (RhD) negative blood group in or immediately after pregnancy to prevent them forming antibodies which may harm their RhD positive babies in future pregnancies. The timing of the anti-D injection is critical, so it is usually offered to a RhD negative mother in pregnancy and immediately after the birth of a RhD positive baby. Failure to administer anti-D to the mother within 72 hours of the birth of their first RhD positive baby can cause Rhesus disease, leaving the mother immune (sensitised) to the anti-D antigen and threatening her ability to have more children safely. In 2022, SHOT received reports of 345 anti-D related errors. In more than two thirds (67.2%) of these, anti-D was either inappropriately not given, or was given too late. More than 79% of these errors took place in clinical settings, such as in delivery suites, antenatal clinics, maternity wards, emergency departments, gynaecology wards, or in the community (home) setting. Nearly 21% were laboratory errors. Anti-D was given unnecessarily in 25.2% of cases, such as in cases where the mothers and babies both had Rhesus positive or Rhesus negative blood groups. In other cases, anti-D was given to mothers who were already sensitised, or they were given the wrong dose, or the anti-D was given to the wrong woman. There were 37 ‘near miss’ anti-D cases, in which patient harm was only avoided because the error was averted by laboratory, nursing or midwifery staff. SHOT pointed out that guidelines for the safe and appropriate administration of anti-D have now been in place for many years and should be reflected in local policies (such as in hospitals) and patient care. Compensation for serious injury caused by negligent transfusions SHOT’s 2022 Annual Report on the safety of transfusions highlights a worrying disregard for the systems, processes and safeguards that patients have a right to expect during their NHS care. The report’s detailed analysis of potentially harmful incidents and errors in patients’ blood transfusions makes clear that most of these arose from very basic mistakes, such as lack of careful patient identification, failing to check patient records or complete standard checklists. Many of these errors coincided with reports of system pressures, such as workload and staffing shortages, or problems with IT, but compliance with basic, fundamental processes would have kept the patient safe. Instead, the shortcut resulted in the patient’s injury or death. Patients have a right to expect the provision of good, basic care, with their safety prioritised at each step of the transfusion process. Where negligent care results in serious injury or the death of the patient, they or their bereaved family are entitled to claim compensation. If you have suffered severe injury as a result of medical negligence or have been contacted by HSIB/HSSIB/MNSI/CQC or NHS Resolution, you can talk to a solicitor, free and confidentially, for advice about how to respond or make a claim by contacting us.
