Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports.

摘要: Abstract Objective: To receive and collate reports of death or major complications transfusion blood components. Design: Haematologists were invited confidentially to report deaths after during October 1996 September 1998. Setting: Hospitals in United Kingdom Ireland. Subjects: Patients who died experienced serious complications, as defined below, associated with red cells, platelets, fresh frozen plasma, cryoprecipitate. Main outcome measures: Death, “wrong” transfused patient, acute delayed reactions, related lung injury, graft versus host disease, post-transfusion purpura, infection transmitted by transfusion. Circumstances relating these cases relative frequency complications. Results: Over 24 months, 366 reported, which 191 (52%) “wrong patient” episodes. Analysis revealed multiple errors identification, often beginning when was collected from the bank. There 22 all causes, including three ABO incompatibility. 12 infections: four bacterial (one fatal), seven viral, one fatal case malaria. During second 164/424 hospitals (39%) submitted a “nil report” return. Conclusions: Transfusion is now extremely safe, but vigilance needed ensure correct identification patient. Staff education should include awareness incompatibility contamination causes life threatening reactions blood. Key messages Blood transfusion, while has several potentially hazards All staff handling be aware importance identity sample, bag at stages Resources directed evaluation methods for improving patients Acute fever collapse may due Microbiological accounted minor component