Do you report the following to SHOT/ SABRE ?

[RR1 39]

We all at some time, receive complaints from medical/surgical staff about delays in the provision of blood components, especially during a massive blood loss event. Generally, on further investigation these reveal communication problems between the teams involved.

In the last two years (2008-2010), if you can recall any complaints that your department investigated regarding similar problems, were these reported to SHOT/SABRE?

Thanks for your help!

[Tonyd 13]

Hello Rashmi

This is an interesting one, as the NPSA originally based their recent Rapid Response Alert on the provision of blood in an emergency (and recommendation to report) on unsubstantiated/uninvestigated rants from frustrated clinicians.

You have to tease out at a local debrief/investigation whether the reported delay (for whatever reason) was an inconvenience or whether it significantly affected the patient.

In cases where it is found that there has been mortaliy/morbidity related to a delay in transfusion, then these should be reported to SHOT in the 'catch-all' category of "I&U" - Inappropriate/Unnecessary/Delayed/Undertransfused.

Not sure they are always reportable to the MHRA, unless you decide it is a failure of your QMS that has led to the delay

Hope that helps

Best wishes

Tony

[RR1 39]

Thanks Tony,

Yes, I see it can depend on findings of the investigation, but as we are required to report significant event /suspected events to MHRA as soon as possible, I would have thought that at least an initial notification report should be placed pending investigations, which can sometimes take weeks to resolve.

[Tonyd 13]

Hi Rashmi

As per my previous reply, I don't think that many of these cases at all would be reportable to the MHRA, as they fall under the purview of 'the clinical area', so no pressure to get them on to SABRE.

The SABRE help desk may have a view on this

Tony