Missed irradiation of cellular blood components for vulnerable patients: Insights from 10 years of SHOT data.

Transfusion
Johnathon ElliotPaula H B Bolton-Maggs

Abstract

Irradiation of cellular blood components is recommended for patients at risk of transfusion-associated graft-vs-host disease (TA-GvHD). Prestorage leucodepletion (LD) of blood components is standard in the UK since 1999. Analysis of 10 years' reports from UK national hemovigilance scheme, Serious Hazards of Transfusion (2010-2019), where patients failed to receive irradiated components when indicated according to British Society for Haematology guidelines (2011). There were 956 incidents of failure to receive irradiated components all due to errors. One hundred and seventy two incidents were excluded from analysis, 125 of 172 (72.7%) because of missing essential information. No cases of TA-GvHD were reported in this cohort. The 784 patients received 2809 components (number unknown for 67 incidents). Most failures occurred in patients treated with purine analogues (365) or alemtuzumab (69), or with a history of Hodgkin lymphoma (HL) (192). Together these make up 626 of 784 (79.9%). Poor communication is an important cause of errors. Leucodepletion appears to reduce the risk for TA-GvHD. None of 12 cases of TA-GvHD reported to SHOT prior to introduction of LD occurred in patients with conditions recommended for irradiated compone...Continue Reading

References

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Jul 19, 2012·Transfusion·Hazel TinegateUNKNOWN Northern Regional Transfusion Committee
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May 2, 2015·Blood·Ilana KopolovicJeannie Callum
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Nov 20, 2016·British Journal of Haematology·Helen V NewUNKNOWN British Committee for Standards in Haematology
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Dec 14, 2018·Hematology Reports·Palma Manduzio
Aug 19, 2020·British Journal of Haematology·Theodora FoukaneliUNKNOWN BCSH Committee

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Dendrite
SHOT

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