UK Transfusion Laboratory Collaborative: recommended minimum standards for hospital transfusion laboratories

Human errors in manual techniques for ABO/D grouping are associated with potentially lethal outcomes

AIMS/OBJECTIVES

To review if ABO/D grouping errors are more likely to occur with manual intervention compared to automation.

BACKGROUND

Human errors in manual pre-transfusion testing may result in ABO/D-incompatible transfusions and catastrophic outcomes. Accurate ABO/D grouping is a critical part of pre-transfusion testing.

METHODS

This was a retrospective analysis of reports made to Serious Hazards of Transfusion (SHOT) between January 2004 and December 2016 where ABO/D grouping errors led to the transfusion of an incorrect blood component to review if errors are more likely to occur with manual intervention compared to automation.

RESULTS

In 148 of 158 (93%) ABO/D grouping errors, manual intervention took place. In the remaining 10, causes were not reported. No errors occurred with full automation. Interpretation errors occurred in 86 of 148 (58%) and 42 of 148 (28%) transcription errors, and in 20 of 148, wrong or no samples were selected. Of 148 errors, 21 (14%) resulted in ABO-incompatible transfusion, with one death in 2004 due to an interpretation error in a manual ABO group. In 30 of 148 (20%), D-positive red cells were given to D-negative recipients, where three women of child-bearing potential became sensitised and developed anti-D. ABO grouping errors have reduced from 18 of 539 (3%) of total reports analysed in 2004 (3·3%) to 3 of 3091 (0·10%) in 2016.

CONCLUSIONS

Where manual testing cannot be avoided, results should be confirmed using automated techniques as soon as possible, and a back-up process should be available 24/7. SHOT data confirm that manual interventions are prone to human error, especially in transcription and interpretation, and demonstrate a continuing need for appropriate serological knowledge and understanding by transfusion laboratory staff to underpin safety provided by automation and information technology (IT).

An experience of the introduction of a blood bank automation system (Ortho AutoVue Innova) in a regional acute hospital

This paper reports on an evaluation of the introduction of a blood bank automation system (Ortho AutoVue(®) Innova) in a hospital blood bank by considering the performance and workflow as compared with manual methods. The turnaround time was found to be 45% faster than the manual method. The concordance rate was found to be 100% for both ABO/Rh(D) typing and antibody screening in both of the systems and there was no significant difference in detection sensitivity for clinically significant antibodies. The Ortho AutoVue(®) Innova automated blood banking system streamlined the routine pre-transfusion testing in hospital blood bank with high throughput, equivalent sensitivity and reliability as compared with conventional manual method.

UK Transfusion Laboratory Collaborative: minimum standards for staff qualifications, training, competency and the use of information technology in hospital transfusion laboratories 2014

The SHOT Adverse Incident Reporting Scheme has consistently reported an unacceptably high level of errors originating in the laboratory setting. In 2006 an initiative was launched in conjunction with the IBMS, SHOT, RCPath, BBTS, UK NEQAS, the NHSE NBTC and the equivalents in Scotland, Wales and Northern Ireland that led to the formation of the UK TLC. The UK TLC in considering the nature and spread of the errors documented by SHOT concluded that a significant proportion of these errors were most likely to be related to either the use of information technology or staff education, staffing levels, skill mix, training and competency issues. In the absence of any formal guidance on these matters, the UK TLC developed a series of recommendations using the results of two laboratory surveys conducted in 2007 and 2008.

Challenges of a negative work load and implications on morale, productivity and quality of service delivered in NHS laboratories in England

The National Health Service (NHS) is a term used to describe the publicly funded healthcare delivery system providing quality healthcare services in the United Kingdom. There are several challenges militating against the effective laboratory service delivery in the NHS in England. Biomedical scientists work in healthcare to diagnose disease and evaluate the effectiveness of treatment through the analysis of body fluids and tissue samples from patients. They provide the "engine room" of modern medicine with 70% of diagnosis based on the laboratory results generated by them. This review involved the search of literature for information on working condition of biomedical scientist in the NHS in England. Laboratory service delivery in the NHS in England faces numerous daunting challenges; staffing levels in the last few years have become dangerously low, less remunerated, relatively less experienced and predominantly band 5's, multidisciplinary rather than specialty based, associated with working more unsocial hours without adequate recovery time, de-banding of staff, high staff turnaround, profit and cost driven rather than quality. These factors has resulted in burn out, low morale, high sickness absences, increased error rate, poor team spirit, diminished productivity and suboptimal laboratory service delivery. There is the urgent need to retract our steps on unpopular policies to ensure that patient care is not compromised by ensuring adequate staffing level and mix, ensuring adequate remuneration of laboratory staff, implementing evidenced-based specialty oriented service, determining the root cause/s for the high staff turnover and implementing corrective action, identifying other potential sources of waste in the system rather than pruning the already dangerously low staffing levels and promoting a quality delivery side by side cost effectiveness.

Serious Hazards of Transfusion (SHOT) haemovigilance and progress is improving transfusion safety

The Serious Hazards of Transfusion (SHOT) UK confidential haemovigilance reporting scheme began in 1996. Over the 16 years of reporting, the evidence gathered has prompted changes in transfusion practice from the selection and management of donors to changes in hospital practice, particularly better education and training. However, half or more reports relate to errors in the transfusion process despite the introduction of several measures to improve practice. Transfusion in the UK is very safe: 2·9 million components were issued in 2012, and very few deaths are related to transfusion. The risk of death from transfusion as estimated from SHOT data in 2012 is 1 in 322 580 components issued and for major morbidity, 1 in 21 413 components issued; the risk of transfusion-transmitted infection is much lower. Acute transfusion reactions and transfusion-associated circulatory overload carry the highest risk for morbidity and death. The high rate of participation in SHOT by National Health Service organizations, 99·5%, is encouraging. Despite the very useful information gained about transfusion reactions, the main risks remain human factors. The recommendations on reduction of errors through a ‘back to basics’ approach from the first annual SHOT report remain absolutely relevant today.

When and why is blood crossmatched? A prospective survey of transfusion laboratory practice in two regions in the north of England

BACKGROUND AND OBJECTIVES

This study was undertaken to provide data relating to the timing of laboratory crossmatch procedures, and the source of requests for out of hours crossmatch, to support interpretation of error reports originating in the transfusion laboratory, received by the Serious Hazards of Transfusion haemovigilance scheme.

MATERIALS AND METHODS

Data on the timing, origin and urgency of all crossmatch requests were collected in 34 hospitals in northern England over a 7-day period in 2008. Additional data on clinical urgency were collected on crossmatches that were performed out of hours.

RESULTS

Data were obtained on 2423 crossmatches, including 610 (25.2%) performed outside core hours. 30.3% of out of hours crossmatch requests were for transfusions that were set up outside 4 h of completion of the crossmatch.

CONCLUSION

2008 Serious Hazards of Transfusion data showed that 29/39 (74%) of laboratory errors resulting in 'wrong blood' occurred out of hours whilst our audit shows that only 25% of crossmatch requests are made in that time period, suggesting that crossmatching performed outside core hours carries increased risks. The reason for increased risk of error needs further research, but 25 laboratories had only one member of staff working out of hours, often combining blood transfusion, haematology and coagulation work. A total of 25% of out of hours requests were not clinically urgent. Hospitals should develop policies to define indications for out of hours transfusion testing, empower laboratory staff to challenge inappropriate requests and ensure that staffing and expertise is appropriate for the workload at all times.