Incorrect Blood Component Transfused (IBCT) Cumulative Data

Definition:

Wrong component transfused (WCT)
Where a patient was transfused with a blood component of an incorrect blood group, or which was intended for another patient and was incompatible with the recipient, which was intended for another recipient but happened to be compatible with the recipient, or which was other than that prescribed e.g. platelets instead of red cells.

Specific requirements not met (SRNM)
Where a patient was transfused with a blood component that did not meet their specific requirements, for example irradiated components, human leucocyte antigen (HLA)-matched platelets when indicated, antigen-negative red cell units for a patient with known antibodies, red cells of extended phenotype for a patient with a specific clinical condition (e.g. haemoglobinopathy), or a component with a neonatal specification where indicated. (This does not include cases where a clinical decision was taken to knowingly transfuse components not meeting the specification in view of clinical urgency).

SHOT has collected data on incorrect blood component transfused (IBCT) since 1996. Originally, this category included all error reports, for example, avoidable transfusions, handling and storage errors, administration of anti-D immunoglobulin, and right blood to the right patient. In later years, these categories were separated out and reported in their own chapters.

The figure above only includes wrong component transfused (WCT) and specific requirements not met (SRNM) cases (plus some miscellaneous cases that did not fit easily into these categories. The remaining cases for Anti-D Ig, ADU, HSE and RBRP (where identifiable) have been included in the data drawers for those categories.

Recent Recommendations

If staff are interrupted and/or distracted during the final pre-administration check, they must re-start the process from the beginning (BSH Robinson et al. 2018)
Action: All staff in transfusion, ward managers
Collection is a critical step in the transfusion process – barriers such as collection checks and smart refrigerators must be in place to reduce errors
Action: Transfusion service managers, hospital transfusion teams and risk management
teams
Ensure that competency and training is effective and robust. Competency-assessment must be
of value, rather than a tick box exercise
Action: Training leads
Laboratory staff providing training should have knowledge of transfusion to ensure training is of
sufficient standard, in line with UKTLC standards
Action: Transfusion laboratory managers
LIMS must be used to their full potential to ensure the correct component is issued to the patient
which meets all requirements for their clinical picture
Action: LIMS suppliers, transfusion service managers

IBCT Resources

Please also see relevant videos on ABO-incompatible transfusions, pre-transfusion blood sampling and the pre-administration blood component transfusion bedside check. These can be accessed on this page