Since 1996, the hemovigilance surveillance system in the United Kingdom has collected and published yearly reports on the serious hazards of transfusions (SHOT). In 2016, almost 2.5 million components were transfused in the U.K., including 1.8 million red blood cell (RBC) transfusions. The number of deaths in the U.K. due to ABO-incompatible transfusions have decreased during the last decade (15 deaths from 1996-2005 compared to 5 deaths from 2006-2016), and only 12.5% of all SHOT reports in 2016 were due to adverse reactions. Almost all of the SHOT reports filed during 2016 were due to errors (2688/3091, 87%), many of which were preventable. Only 3 ABO-incompatible RBC transfusions occurred, but there were 264 near misses that were caught in the laboratory or at the patient’s bedside. Furthermore, over half of the deaths (14/26, 53.8%) due to transfusions in 2016 were due to transfusion-associated circulatory overload (TACO). Thus, the key recommendations from the 2016 SHOT Report are use of bedside checklists to prevent incompatible errors and to check for pulmonary complications that may be associated with TACO.
Reference:
Over half of the deaths (14/26, 53.8%) due to transfusions in 2016 were due to transfusion-associated circulatory overload (TACO). (Like in 2013)
TACO is actually the most important and frequent cause of death!
One unique unit transfusion must be mandatory in non-bleeding hemodinamicaly stable patients! The most often DO NOT DO Recommendation!
And premedication with diuretics must be study in large RCT!
Based on the SHOT recommendation, the NHSBT Patient Blood Management Team have produced the bedside checklist in a handy lanyard card. They can be ordered for free – but stocks are limited. Just ask your local Transfusion Practitioner or Patient Blood Management Practitioner.
As Haematologist practising in developing country (Nigeria), this is very useful and it is an eye opener.
very interesting.