title: Errors in anti-D immunoglobulin administration: retrospective analysis of 15 years of reports to the UK confidential haemovigilance scheme.
abstract: 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.
  
  
  METHODS
  Retrospective review of cumulative reporting to the UK confidential haemovigilance scheme, Serious Hazards of Transfusion (SHOT), between 1996 and 2011.
  
  
  METHODS
  Obstetric departments in the UK.
  
  
  METHODS
  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.
  
  
  METHODS
  Reported number of events and their causes, and morbidity and mortality associated with errors.
  
  
  RESULTS
  In 15 years 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.
authors.affiliation: University of Manchester, and Serious Hazards of Transfusion Office, Manchester Blood Centre, Manchester, UK. paula.bolton-maggs@manchester.ac.uk
authors.forename: P H B
authors.initials: PH
authors.lastname: Bolton-Maggs
authors.forename: T
authors.initials: T
authors.lastname: Davies
authors.forename: D
authors.initials: D
authors.lastname: Poles
authors.forename: H
authors.initials: H
authors.lastname: Cohen
mesh_terms: D058731:Blood Safety; D004899:Erythroblastosis, Fetal / Q000209:etiology / Q000517:prevention & control; D005260:Female; D006801:Humans; D007155:Immunologic Factors / Q000627:therapeutic use*; D008508:Medication Errors / Q000009:adverse effects / Q000517:prevention & control / Q000706:statistics & numerical data*; D011247:Pregnancy; D011250:Pregnancy Complications, Hematologic / Q000517:prevention & control*; D012189:Retrospective Studies; D012203:Rh Isoimmunization / Q000517:prevention & control*; D018029:Rho(D) Immune Globulin / Q000627:therapeutic use*; D006113:United Kingdom
chemical_list: D007155:Immunologic Factors; D018029:Rho(D) Immune Globulin