Errors in anti-D immunoglobulin administration: retrospective analysis of 15years of reports to the UK confidential haemovigilance scheme
Errors in anti-D immunoglobulin administration: retrospective analysis of 15years of reports to the UK confidential haemovigilance scheme
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DOI：
10.1111/1471-0528.12175
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发表时间：
2013-06-01
影响因子：
5.8
通讯作者：
Cohen, H.
中科院分区：
文献类型：
--
作者：
Bolton-Maggs, P. H. B.;Davies, T.;Cohen, H.
目的探讨RhD抗原阴性妇女在使用抗-D免疫球蛋白时出现的错误及其对妊娠期间和妊娠后的临床影响，并提出减少这些错误的策略。设计对1996至2011年间向英国机密血液警戒计划--严重输血危险(Shot)--的累计报告进行回顾。设置英国的产科部门。在怀孕期间或出生后需要抗D免疫球蛋白以防止RhD敏感性的人群母亲。方法医院输液组将不良事件上报至枪击数据库。主要结果衡量报告的事件数量及其原因，以及与错误相关的发病率和死亡率。结果在15年的报告中，Sort血液警戒系统共显示1211个与使用抗-D免疫球蛋白有关的错误，特别是关于遗漏或延迟使用的错误(2011年报告的157/249例，占63%)。抗-D免疫球蛋白错误占2011年所有SET报告的13.7%(249/1815)。在19个病例中，有19例未能识别出已经患有RhD敏感症的妇女，随后对怀孕进行了次优监测。其中9名婴儿患有胎儿和新生儿溶血性疾病(HDFN)：1名新生儿死亡，3名需要输血红细胞。结论婴儿和他们的母亲仍然处于可避免错误的风险中。在国家和地方各级更加积极地关注进一步的教育和培训，特别是助产士的教育和培训，是绝对必要的。我们建议使用特制的反D管理流程图，并在当地改编成核对表，以帮助减少错误。
Objective To highlight the errors associated with the use of anti-D immunoglobulin in RhD antigen-negative women, and their resultant clinical impact during and after pregnancy, and to suggest strategies to reduce these errors. Design Retrospective review of cumulative reporting to the UK confidential haemovigilance scheme, Serious Hazards of Transfusion (SHOT), between 1996 and 2011. Setting Obstetric departments in the UK. Population Mothers who require anti-D immunoglobulin to prevent RhD sensitisation during pregnancy or after birth. Methods Hospital transfusion teams reported adverse events to the SHOT database. Main outcome measures Reported number of events and their causes, and morbidity and mortality associated with errors. Results In 15years of reporting, SHOT haemovigilance has shown a total of 1211 errors related to the administration of anti-D immunoglobulin, particularly regarding omission or late administration (157/249 or 63% reported in 2011). Anti-D immunoglobulin errors comprised 13.7% (249/1815) of all SHOT reports in 2011. Failure to recognise women who already have RhD sensitisation occurred in 19 cases, and was followed by suboptimal monitoring of the pregnancy. Nine of the infants suffered haemolytic disease of the fetus and newborn (HDFN): one resulted in neonatal death and three required red cell transfusion. Conclusions Babies as well as their mothers remain at risk from avoidable errors. More active attention at national and local levels to further education and training, particularly for midwives, is an absolute necessity. We recommend the use of a SHOT-devised anti-D administration flowchart, adapted locally into a checklist, to help reduce errors.