Thread by @TransfusionWM

I had a personal request to do a tweetorial for the #haemSpRs on haemovigilance. Here goes. A #blooducation 🧵

Haemovigilance is a systematic surveillance of adverse reactions and adverse events related to transfusion’ with the aim of improving transfusion safety.
transfusionguidelines.org/transfusion-ha…

We are very lucky in the UK to have @SHOTHV1, one of the first in the world to collate adverse events relating to transfusion - since the 1990s.

When an adverse event occurs in a hospital, the transfusion team may identify the initial problem (e.g. Wrong Blood In Tube, WBIT), may be notified directly (e.g. clinician reports febrile reaction), or something else (e.g. case review identifies a delay to transfusion).

Let’s talk through a WBIT event to see who does what and how it all fits together.

A sample (2) arrives in the lab and types as A+. But the patient has a historical sample (1) showing they are O-. Blood bank flag the error and request a repeat sample from the clinical area.

At this point we don’t know if the current or historic sample is the WBIT. Any blood issued to the patient should be withdrawn while the error is investigated.

A repeat sample (3) confirms the group as O-. So sample (2) is the WBIT.

Blood bank will
1.Check lab records for any samples taken in the same clinical area at a similar time that have grouped as O-. Is this a question of transposition of two patients’ samples and labels? i.e. is there another patient who has had a WBIT?

2.Notify haem, biochem etc of the WBIT so any other samples taken at the same time as sample (2) can be nullified.
3.Ensure the correct sample is tested and any required blood issued to the patient

These are things done to make the situation safe; “corrective actions”

Blood bank will notify the transfusion practitioner will look at who took the sample and try to work out what happened. The TP will
1.Check the training records – is the person who took the sample trained and in date?
2.Speak to the person who took the sample

People usually feel very guilty and regretful when they realise they have been involved in an incident. However TPs want to find out how the error occurred, *not* so they can apportion blame, but so they can put measures in place "preventative actions" to stop it happening again.

The best information is what the person involved provides before they’ve had long to think about what happened. The TPs will interview them ASAP. They will also suspend their sample-taking privileges until it is understood what has happened and any retraining has taken place.

In this case, a doctor was writing a patient clerking when the emergency alarm went. They were called to a patient having a GI bleed. The bedspace was chaotic, another doctor took samples and handed them to them to label. They took the samples away from the bedspace and ...

...accidentally labelled them from the notes of the patient they’d been clerking when the alarm went off.

One action here was to retrain the individual, but this highlights a wider problem around preventing others from making the same mistake. Training can improve this.

But bedside IT systems are probably the best way to prevent WBITs and many hospitals are implementing them now. pubmed.ncbi.nlm.nih.gov/30549289/

An example of a preventative action in this case would be retraining the individual (low impact) or implementing bedside IT (higher impact)

The incident would be reported through the Trust reporting system (e.g. Datix) which will allow monitoring of trends (e.g. sudden increase in WBITs). In transfusion we monitor our own events and discuss them at HTT/HTC, where specific preventative actions can be proposed.

All this adds weight to any business cases that may need to be developed, or e.g. gain support from the medical director to improve access to training.

The event will also be reported to @SHOTHV1 who collate the reports and publish their findings including trends and key messages and learning each year. shotuk.org/shot-reports/

Learning from reports helps hospitals implement change without having to experience all the events themselves. Collating reports can also provide evidence to make national recommendations e.g. the recent CAS alert relating to transfusion delays cas.mhra.gov.uk/ViewandAcknowl…

SHOT accept reports relating to errors, reactions inc near misses and more recently “ACE” acknowledging continuing excellence”. They collect reports on blood components and some products: SD FFP/Octaplas, anti-D +PCC. Reporting categories are here shotuk.org/wp-content/upl…

Reporting to SHOT is voluntary but professionally mandated.

SABRE is the MHRA reporting system for blood safety incidents. It is a legal requirement. SHOT and SABRE reports are now logistically made through the same portal, however there are differences in what they accept.

SABRE accept reports for component SAE and SARs
🌟SAR: Death/life-threatening/disabling/incapacitating reaction, or results in/prolongs hospitalisation/morbidity
🌟SAE: any serious adverse event related to collection/testing/processing/storage/distribution of blood/components

In short
❌SABRE don’t accept near misses
❌SABRE don’t accept reports of events outside the lab, unless the patient comes to harm
☑️SABRE can impose sanctions and demand corrective actions of individual sites (SHOT do not have a role in “policing” hospitals)

For transfusion reactions where there is potential for implication of the transfused component, NHSBT must also be informed, ASAP. This may be when there is concern about
🦠Bacterial contamination
🩸TRALI

This is so any appropriate donor testing can be done and any associated components recalled so they are not transfused to other patients. More information is available here hospital.blood.co.uk/diagnostic-ser…

That’s my not so quick run through incident reporting.
What did I miss @TransfusionGeek @JessCaldecott @UHB_Transfusion @SHOTHV1 @shshsid ?!

Oh, and the doctor who took the WBIT? That was me, over 15 years ago. Learn from my mistake!