Ready to upload
Adverse Occurrence type:
Time to detection:
Alerting signals, symptoms, evidence of occurrence:
An elderly female on immunosuppressive therapy received 7 units of red cells in summer 2012 during surgery for a bowel problem. The recipient was first tested in April 2013 because of mildly abnormal liver function tests (LFT) and found to be hepatitis B surface antigen (HBsAg) positive, low level IgM antibodies to hepatitis B core (anti-HBc IgM) , hepatitis B e antigen (HBeAg) positive.
Demonstration of imputability or root cause:
Of the seven donors investigated, one was found to be HBV deoxyribonucleic acid (DNA) reactive on the index archive sample. The donor was found to be anti-HBc positive on a subsequent sample. An archive sample from 2011 was also antibody to hepatitis B core (anti-HBc) positive, but HBV DNA negative.
Bolton-Maggs, PHB (Ed), D Poles, A Watt and D Thomas on behalf of the Serious Hazards of Transfusion (SHOT) Steering Group, UK (2014). The 2013 Annual SHOT Report (2014), p 149. ISBN 978-0-9558648-6-5
OK FOR EVI; ONLY REFERENCE DANIELA