Blood transfusion

From the Serious Hazards of Transfusion Reports (SHOT) 1996–2008, which one of the

following conditions has resulted in the HIGHEST number of deaths in which a

transfusion reaction was felt to be either causal or contributory?

a) Transfusion-related acute lung injury

b) Incorrect blood component transfused

c) Acute transfusion reaction

d) Transfusion-transmitted infections

e) Transfusion-associated graft versus host disease

Answer: a

Explanation

The first SHOT report looked at transfusion complications from data collected in

1996/1997. Since then, reports have been produced initially biannually and since

2003 on an annual basis. SHOT has a number of aims including the building of an

evidence base of transfusion hazards, to make evidence-based and targeted recommendations

for improvements in transfusion practice and to work with the national

and international bodies responsible for transfusion safety. Reporting is voluntary

but strongly encouraged by a number of organisations including the Department of

Health as is advocated in their document ‘Better Blood Transfusion’. To aid reporting

SHOT, in conjunction with the Medicines and Healthcare products Regulatory

Agency (MHRA), have set up an internet-based reporting system called SABRE

(Serious Adverse Blood Reactions and Events). In time it is expected that reporting

will become compulsory. Indications from the reports are that both the number of

serious adverse events and the mortality directly related to transfusion have fallen

since reporting first began. In total SHOT has recorded 125 deaths of which the most

(40) have been attributed to transfusion-related acute lung injury (TRALI). This is

likely to change as the number of reported TRALIs has fallen dramatically since the

inception of TRALI reduction strategies in 2003–4. Incorrect blood and component

transfusion, acute transfusion reaction, graft versus host disease and transfusiontransmitted

infection (in that order) make up the rest of the ‘top five’ transfusionrelated

deaths.

Reference

Serious Hazards of Transfusion (SHOT) website. Online at www.shotuk.org (Accessed

30 October 2009)