{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,20]],"date-time":"2026-09-20T12:34:11Z","timestamp":1789907651919,"version":"4.0.1"},"reference-count":12,"publisher":"Wiley","issue":"7","license":[{"start":{"date-parts":[[2013,3,13]],"date-time":"2013-03-13T00:00:00Z","timestamp":1363132800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["obgyn.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["BJOG"],"published-print":{"date-parts":[[2013,6]]},"abstract":"<jats:sec><jats:title>Objective<\/jats:title><jats:p>To highlight the errors associated with the use of anti\u2010<jats:styled-content style=\"fixed-case\">D<\/jats:styled-content> immunoglobulin in <jats:styled-content style=\"fixed-case\">R<\/jats:styled-content>h<jats:styled-content style=\"fixed-case\">D<\/jats:styled-content> antigen\u2010negative women, and their resultant clinical impact during and after pregnancy, and to suggest strategies to reduce these errors.<\/jats:p><\/jats:sec><jats:sec><jats:title>Design<\/jats:title><jats:p>Retrospective review of cumulative reporting to the <jats:styled-content style=\"fixed-case\">UK<\/jats:styled-content> confidential haemovigilance scheme, <jats:styled-content style=\"fixed-case\">S<\/jats:styled-content>erious <jats:styled-content style=\"fixed-case\">H<\/jats:styled-content>azards of <jats:styled-content style=\"fixed-case\">T<\/jats:styled-content>ransfusion (<jats:styled-content style=\"fixed-case\">SHOT<\/jats:styled-content>), between 1996 and 2011.<\/jats:p><\/jats:sec><jats:sec><jats:title>Setting<\/jats:title><jats:p>Obstetric departments in the <jats:styled-content style=\"fixed-case\">UK<\/jats:styled-content>.<\/jats:p><\/jats:sec><jats:sec><jats:title>Population<\/jats:title><jats:p>Mothers who require anti\u2010<jats:styled-content style=\"fixed-case\">D<\/jats:styled-content> immunoglobulin to prevent <jats:styled-content style=\"fixed-case\">R<\/jats:styled-content>h<jats:styled-content style=\"fixed-case\">D<\/jats:styled-content> sensitisation during pregnancy or after birth.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Hospital transfusion teams reported adverse events to the <jats:styled-content style=\"fixed-case\">SHOT<\/jats:styled-content> database.<\/jats:p><\/jats:sec><jats:sec><jats:title>Main outcome measures<\/jats:title><jats:p>Reported number of events and their causes, and morbidity and mortality associated with errors.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>In 15\u00a0years of reporting, <jats:styled-content style=\"fixed-case\">SHOT<\/jats:styled-content> haemovigilance has shown a total of 1211 errors related to the administration of anti\u2010D immunoglobulin, particularly regarding omission or late administration (157\/249 or 63% reported in 2011). Anti\u2010D immunoglobulin errors comprised 13.7% (249\/1815) of all <jats:styled-content style=\"fixed-case\">SHOT<\/jats:styled-content> reports in 2011. Failure to recognise women who already have <jats:styled-content style=\"fixed-case\">R<\/jats:styled-content>h<jats:styled-content style=\"fixed-case\">D<\/jats:styled-content> 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 (<jats:styled-content style=\"fixed-case\">HDFN<\/jats:styled-content>): one resulted in neonatal death and three required red cell transfusion.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>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 <jats:styled-content style=\"fixed-case\">SHOT<\/jats:styled-content>\u2010devised anti\u2010<jats:styled-content style=\"fixed-case\">D<\/jats:styled-content> administration flowchart, adapted locally into a checklist, to help reduce errors.<\/jats:p><\/jats:sec>","DOI":"10.1111\/1471-0528.12175","type":"journal-article","created":{"date-parts":[[2013,3,8]],"date-time":"2013-03-08T14:02:29Z","timestamp":1362751349000},"page":"873-878","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":25,"title":["Errors in anti\u2010<scp>D<\/scp> immunoglobulin administration: retrospective analysis of 15\u00a0years of reports to the <scp>UK<\/scp> confidential haemovigilance scheme"],"prefix":"10.1111","volume":"120","author":[{"given":"PHB","family":"Bolton\u2010Maggs","sequence":"first","affiliation":[{"name":"University of Manchester, Manchester UK"},{"name":"Serious Hazards of Transfusion (SHOT) Office, Manchester Blood Centre, Manchester UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"T","family":"Davies","sequence":"additional","affiliation":[{"name":"Serious Hazards of Transfusion (SHOT) Office, Manchester Blood Centre, Manchester UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"D","family":"Poles","sequence":"additional","affiliation":[{"name":"Serious Hazards of Transfusion (SHOT) Office, Manchester Blood Centre, Manchester UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"H","family":"Cohen","sequence":"additional","affiliation":[{"name":"Department of Haematology University College London Hospitals NHS Foundation Trust and University College London London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2013,3,13]]},"reference":[{"key":"e_1_2_6_2_1","unstructured":"NICE.Routine antenatal anti\u2010D prophylaxis for women who are RhD\u2010negative. Review of NICE Technology Appraisal Guidance 41. NICE technology appraisal guidance 156.2011. [www.nice.org.uk\/TA156]. Accessed 9 September 2012."},{"key":"e_1_2_6_3_1","unstructured":"ParkerJ WrayJ GoochA RobsonS QureshiH.Guidelines for the use of prophylactic anti\u2010D immunoglobulin.BCSH Guidelines: British Committe for Standards in Haematology 2006[http:\/\/www.bcshguidelines.com\/documents\/Anti-D_bcsh_07062006.pdf]. Accessed 12 July 2012."},{"key":"e_1_2_6_4_1","unstructured":"BrennandJE CameronAD.The use of Anti\u2010D Immunoglobulin for Rhesus D Prophylaxis.Green\u2010top Guideline RCOG. [www.rcog.org.uk\/files\/rcog-corp\/GTG22AntiD.pdf 2011;22]. Accessed 12 July 2012."},{"key":"e_1_2_6_5_1","first-page":"82","article-title":"The 2011 Annual SHOT report","author":"Bolton\u2010Maggs PHB","year":"2012","journal-title":"Annu Rep Summ"},{"key":"e_1_2_6_6_1","unstructured":"National Haemovigilance Office Report (Eire) 2008\/2009. Anti\u2010D events2011. pp.41\u20104."},{"key":"e_1_2_6_7_1","article-title":"SHOT Annual report 2005","volume":"39","author":"Stainsby D","year":"2006","journal-title":"Annu Rep Summ"},{"key":"e_1_2_6_8_1","first-page":"65","article-title":"SHOT Annual report 2007","author":"Taylor C","year":"2008","journal-title":"Annu Rep Summ"},{"key":"e_1_2_6_9_1","first-page":"82","article-title":"SHOT Annual report 2008","volume":"899","author":"Taylor C","year":"2009","journal-title":"Annual Report Summary"},{"key":"e_1_2_6_10_1","unstructured":"Health Service Circular.Better Blood Transfusion\u2010Safe and Appropriate use of Blood HSC 2007\/001. [www.dh.gov.uk\/prod_consum_dh\/groups\/dh_digitalassets\/documents\/digitalasset\/dh_080803.pdf 2007]. Accessed 14 May 2012."},{"key":"e_1_2_6_11_1","unstructured":"Educational material for midwives and obstetricians. [www.transfusionguidelines.org\/Index.aspx?Publications=NTC&Section=27&pageid=982]. Accessed 13 March 2012."},{"key":"e_1_2_6_12_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMsa0810119"},{"key":"e_1_2_6_13_1","unstructured":"National Blood Transfusion Audit website where audit schedule is listed and reports published. [http:\/\/hospital.blood.co.uk\/safe_use\/clinical_audit\/national_comparative\/index.asp]. Accessed 14 November 2012."}],"container-title":["BJOG: An International Journal of Obstetrics &amp; Gynaecology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/api.wiley.com\/onlinelibrary\/tdm\/v1\/articles\/10.1111%2F1471-0528.12175","content-type":"unspecified","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/obgyn.onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/1471-0528.12175","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,11,22]],"date-time":"2023-11-22T10:16:46Z","timestamp":1700648206000},"score":1,"resource":{"primary":{"URL":"https:\/\/obgyn.onlinelibrary.wiley.com\/doi\/10.1111\/1471-0528.12175"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2013,3,13]]},"references-count":12,"journal-issue":{"issue":"7","published-print":{"date-parts":[[2013,6]]}},"alternative-id":["10.1111\/1471-0528.12175"],"URL":"https:\/\/doi.org\/10.1111\/1471-0528.12175","archive":["Portico"],"relation":{},"ISSN":["1470-0328","1471-0528"],"issn-type":[{"value":"1470-0328","type":"print"},{"value":"1471-0528","type":"electronic"}],"subject":[],"published":{"date-parts":[[2013,3,13]]},"assertion":[{"value":"2013-01-04","order":1,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2013-03-13","order":2,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}