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Avoidable mistakes still occurring

18 March, 2013

Avoidable mistakes still occurring

A 15-year study has shown that unnecessary rhesus disease errors are still being made. Posted: 18 March 2013 by Hollie Ewers

A 15-year study has shown that unnecessary rhesus disease errors are still being made.

Anti-d being administered

Researchers looked at records taken from the SHOT database from 1996 to 2011 and found a total of 1211 errors related to the administration of anti-D immunoglobulin to tackle rhesus disease (also known as Rhesus Haemolytic Disease of the Fetus and Newborn or Rh HDFN).

The main cause for 50% of all reported errors was omission or late administration of anti-D. Of these, 90% occurred through avoidable clinical errors such as delayed administration, inadequate labelling and poor documentation.

Over the 15 years, clinical errors were responsible for 72.5% of all reports and laboratory errors for 27.5%.

Other concerning errors included 280 cases of anti-D being wrongly administered to women with a Rhd positive blood type, 108 cases administered to women who were already sensitised to RhD and 50 cases due to inadequate storage and stock management.

These errors resulted in 19 cases where detectable anti-D was wrongly attributed to prophylaxis, nine cases of babies suffering Rh HDFN with one neonatal death and three babies requiring blood transfusions.

The study’s co-author Dr Paula Bolton-Maggs form the University of Manchester said: ‘Our findings show that over the 15 year reporting period the same mistakes were being made repeatedly by clinical and laboratory staff.

‘Failure of staff to follow basic protocols, poor communication and inadequate interpretation of laboratory records compounds a poor understanding of the significance of good practice around anti-D Ig in maternity services.

‘These are clinically significant problems that require active attention at a national and local level as reported errors could be avoided by putting in place appropriate checks.’

The RCM’s director for midwifery Louise Silverton welcomed the report and said: ‘The RCM expects each maternity unit to have systems in place to ensure that all women requiring the anti-D prophylaxis injection receive it regardless of their length of postnatal stay, especially where they live outside the unit's catchment area.

‘This is especially important given the increase in births and pressure on maternity services. We need more midwives and more midwifery visits in the community so they can administer anti-D at home under the agreed time limits and spend time with women after they have given birth.’

The study, published in BJOG, calls for further education and training for obstetric staff both in hospitals and in the community to help reduce the rate of errors.

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