Record number:
1035
Adverse Occurrence type:
MPHO Type:
Alerting signals, symptoms, evidence of occurrence:
Between March 1, 2004, and May 31, 2006, bacterial culture testing was performed on 1,004,206 donations; of these, 186 (1:5,399) had confirmed-positive culture results. Transfusion of all but 1 of the associated 293 components was prevented. During this period, 20 septic transfusion reactions were reported, including 3 fatalities (1:498,711 fatalities per distributed component), which implicated screened-negative apheresis PLT products. Bacterial cultures and sensitivity were carried out on both patients and platelet components. Two fatalities were caused by S. aureus.
Demonstration of imputability or root cause:
Septic transfusion reaction was defined by clinical criteria associated with a culture-positive residual component and a culture-positive recipient demonstrating the same bacteria as determined by antibiotic sensitivity and/or pulsed-field gel electrophoresis or by clinical criteria in both recipients of proven culture-positive components.
Imputability grade:
3 Definite/Certain/Proven
Keywords:
References:
Suggest references:
Eder, A.F., Kennedy, J.M., Dy, B.A., Notari, E.P., Weiss, J.W., Fang, C.T., Wagner, S., Dodd, R.Y., Benjamin, R.J., and ARC Regional Blood Centers (2007). Bacterial screening of apheresis platelets and the residual risk of septic transfusion reactions: the American Red Cross experience (2004-2006).Transfusion 47(7):1134-42.
Harvey AR, Basavaraju SV, Chung KW, Kuehnert. MJ. Transfusion-related adverse reactions reported to the National Healthcare Safety Network Hemovigilance Module, United States, 2010 to 2012. Transfusion 2014 Nov 5. doi: 10.1111/trf.12918. [Epub ahead of print]