RESULTS FROM THE
2006
SHOT REPORT
SHOT report 2006
Cumulative data 1996 – 2006
Comparison of Report Types 1996 – 2006
Mortality & morbidity 1996 – 2006
Total
IBCT
ATR
HTR
PTP
TAGVHD
TRALI
TTI
47
7
2
6
1
13
8
10
15
4
4
1
0
0
6
0
47
13
7
1
1
0
25
0
109
24
13
8
2
13
39
10
Major morbidity definitely or
probably due to transfusion
reaction
315
100
17
29
13
0
118
38
Minor or no morbidity due to
transfusion reaction
3324
2582
387
280
31
0
38
6
3639
2682
404
309
44
0
156
44
0
0
195
54
Death definitely due to
transfusion (Imputability 3)
Death probably due to
transfusion (Imputability 2)
Death possibly due to
transfusion (Imputability 1)
Subtotal 1
Subtotal 2
Outcome unknown
15
11
3
1
0
0
* Excludes 7 cases from 1998/99 which were not classified
TOTAL
3763
2717
420
318
46
13
Major morbidity was defined as the presence of
one or more of the following;
 Intensive care admission and / or ventilation
 Dialysis and / or renal impairment
 Major haemorrhage from transfusion-induced
coagulopathy
 Intravascular haemolysis
 Potential risk of D sensitisation in a female of
child-bearing potential
Incorrect blood component transfused
(IBCT)
All reported episodes where a patient was
transfused with a blood component or
plasma product which did not meet the
appropriate requirements or that was
intended for another patient
ABO incompatible red cell transfusions
Analysis of 400 IBCT cases in 2006
Type of IBCT Event (2006 Report)
Number (%)
‘Wrong Blood’ Events
54 (14%)
Other pre-transfusion testing errors
28 (7%)
Incorrect group given to ABO/D mismatched transplant
patients
Special requirements not met
8 (2%)
108 (27%)
Inappropriate or unnecessary transfusion
51 (13%)
‘Unsafe’ transfusion due to handling or storage errors
74 (19%)
Events relating to administration of anti-D Immunoglobulin
77 (19%)
Total
400
Errors associated with Anti-D in 2006
Type of event
Total
Site of Error
Lab
Midwife
Medic
26
7
19
-
19
12
7
-
13
6
8
-
9
8
1
-
4
-
4
-
2
1
2
-
2
1
-
1
-
2
-
-
Total cases
77
-
-
-
Total errors
79
37
41
1
Omission or late administration of anti-D Ig
Anti-D Ig given to D positive patient
Anti-D Ig given to patient with immune anti-D
Anti-D Ig given to mother of D negative infant
Anti-D Ig given to wrong patient
Expired anti-D Ig given
Wrong dose of anti-D given
Other (laboratory errors)
Summary of Blood Transfusion Laboratory Errors
Wrong Blood –
ABO
Wrong Blood
- Others
ABO
mismatched
transplant
Special
requirements
not met
Inappropriate
transfusion
Anti-D errors
Unsafe
transfusion
Other pre-tx
testing errors
Total errors
Total
errors
Wrong
sample
Transcription
Interpretation
7
3
3
0
20
-
4
3
-
42
Component
selection
errors
Labelling
Procedural
errors
Testing
-
-
-
1
-
8
5
3
-
-
-
-
3
1
-
-
-
42
-
-
-
-
-
-
-
-
-
-
-
42
-
2
10
5
-
10
15
13
-
-
-
-
-
13
-
29
-
-
1
-
-
23
5
156
3
9
11
55
5
52
21
Acute transfusion reactions
Acute transfusion reactions are defined in this
report as those occurring at any time up to 24
hours following a transfusion of blood or
components, excluding cases of acute reactions
due to incorrect component being transfused,
haemolytic reactions, transfusion-related acute
lung injury (TRALI) or those due to bacterial
contamination of the component.
Acute Transfusion Reactions - 2006
Reaction type
RBCs Plts
(39)
Plts
Apheresis
(11)
Buffy
Coat (8)
FFP
(22)
Multiple
Buffy
Coats
(4)
(1)
Isolated Febrile
18
1
0
0
0
1
Minor Allergic
3
3
1
3
0
0
Anaphylactic /
Severe Allergic
11
5
7
15
3
0
TACO
1
0
0
1
1
0
Hypotension
0
0
0
3
0
0
Febrile with
other symptoms
6
2
0
0
0
0
2.01
11.2
6.6
8.2
-
-
Rate per 100,000
units
Haemolytic Transfusion Reactions
Haemolytic transfusion reactions are split into two
categories: acute and delayed. Acute reactions are
defined as fever and other symptoms/signs of
haemolysis within 24 hours of transfusion, confirmed by
a fall in Hb, rise in LDH, positive DAT and positive
crossmatch. Delayed reactions are defined as fever and
other symptoms/signs of haemolysis more than 24
hours after transfusion, confirmed by one or more of: a
fall in Hb or failure of increment, rise in bilirubin,
positive DAT and positive crossmatch not detectable
pre-transfusion. Simple serological reactions
(development of antibody without pos DAT or evidence
of haemolysis) are excluded.
Time relationship to transfusion
Transfusion Related Acute Lung Injury
(TRALI)
Transfusion Related Acute Lung Injury
was defined in this report as acute
dyspnoea with hypoxia & bilateral
pulmonary infiltrates during or within 6
hours of transfusion, not due to
circulatory overload or other likely cause.
Summary of TRALI cases reported
Completed Reports analysed in 2006
12
Withdrawn by
reporters
Analysed for TRALI
10
2
Highly Likely
Probable
Possible
Unlikely
2
1
4
3
2006 TRALI reports analysed by age and sex
Clinical Speciality / Diagnosis of TRALI cases
Analysis of components implicated in TRALI
Cases of TRALI with relevant donor antibody analysed by
implicated component and by year 2003-2006
Deaths at least possibly due to TRALI and number of
suspected TRALI cases by year 2003-2006
Post-Transfusion Purpura
Post-transfusion purpura was defined as
thrombocytopenia arising 5 - 12 days following
transfusion of red cells associated with the
presence in the patient of antibodies directed
against the HPA (Human Platelet Antigen)
systems
Number of cases of confirmed PTP reported to
SHOT 1996 - 2006
Transfusion Associated-Graft versus Host
Disease
Transfusion associated-graft versus host disease is a
generally fatal immunological complication of
transfusion practice, involving the engraftment and
clonal expansion of viable donor lymphocytes,
contained in blood components in a susceptible host.
TA-GvHD is characterised by fever, rash, liver
dysfunction, diarrhoea, pancytopenia and bone marrow
hypoplasia occurring less than 30 days following
transfusion. The diagnosis is usually supported by
skin/bone marrow biopsy appearance and/or the
identification of donor-derived cells, chromosomes or
DNA in the patient’s blood and/or affected tissues.
Number of cases of TA-GvHD reported to SHOT
1996 - 2006
Transfusion transmitted infections
A report was classified as a TTI if, following investigation:
• The recipient had evidence of infection post-transfusion,
and there was no evidence of infection prior to transfusion
and no evidence of an alternative source of infection;
and, either
• At least one component received by the infected recipient
was donated by a donor who had evidence of the same
transmissible infection,
or
• At least one component received by the infected recipient
was shown to contain the agent of infection.
Confirmed bacterial infections, by year of transfusion and
type of unit transfused (Scotland included from 10/98)