Record number:
1145
Adverse Occurrence type:
MPHO Type:
Alerting signals, symptoms, evidence of occurrence:
Receipt of a thawed donor cord blood unit rendered this product unsuitable for transplantation. The intended recipient has not commenced conditioning. Registry was notified immediately of the receipt of the unsuitable donor cord product, the donor search has been reactivated.
Demonstration of imputability or root cause:
The dry shipper transporting the cryopreserved Donor Cord Blood Unit was despatched with the courier arriving at the intended recipient's transplant centre. On receipt and examination, the external container housing the dry shipper lacked instructions for its orientation during transportation. On opening this container, a flashing red indicator light was noted on the lid of the dry shipper. There was no apparent temperature display device on the exterior. On opening the dry shipper the interior temperature was noted and checked with an in-house thermometer and found to be at +10C. The cord blood unit was in the thawed state. Cord blood identifiers and accompanying documentation were verified as correct. It was apparent that the dry shipper was not charged with liquid nitrogen.
Suggest references:
World Marrow Donor Association.S(P)EAR Committee Annual Report - year 2012