Sponsors

Incident investigation in blood transfusion practice: a review and update

In this article, Serious Hazards of Transfusion laboratory incident specialist Nicola Swarbrick focuses on a specific area of transfusion science haemovigilance practice – incident investigation – that was the topic of a SHOT webinar held last year.

Serious Hazards of Transfusion (SHOT) is the UK’s independent haemovigilance system, collecting and analysing anonymised information on adverse events and reactions in blood transfusion and, where risks and problems are identified, producing recommendations to improve patient safety. Collating the information from events from across the UK gives SHOT a larger number of reports to trend and produce recommendations for safer practice that could not be possible with smaller numbers of events at the individual organisational level. When we improve our practices, this may in turn lead to a reduction in errors and ultimately make the system safer for our patients.

                The United Kingdom Accreditation Service (UKAS)1 and the Blood Safety and Quality Regulations (BSQR) Good Practice Guide (GPG)2 require laboratories to detail the identification and control of adverse events as non-conformances and requires the corrective and preventative actions (CAPA) to be clearly detailed in a non-conformance (NC) report. Using a quality management system to record NCs also allows the investigator to trend adverse events and incorporate continuous quality improvement.

                The 2020 Annual SHOT Report 3 outlined that the number of errors in transfusion practice account for over 80% of reports submitted each year, and learning from these incidents allows SHOT to identify recommendations for safer systems (Fig 1).

Log in or register FREE to read the rest

This story is Premium Content and is only available to registered users. Please log in at the top of the page to view the full text. If you don't already have an account, please register with us completely free of charge.

Latest Issues

Med-Tech Innovation Expo

NEC, Birmingham
5-6 June, 2024

LabMedUK24

DoubleTree by Hilton Brighton Metropole
10-12 June, 2024

Infection Diagnostics Symposium 2024

IET Austin Court, Birmingham
26-27 June, 2024

SHOT Symposium 2024

Mercure Manchester Piccadilly Hotel
9 July, 2024