Human errors in blood supplies ‘cause for concern’

BLOOD supplied to 69 people last year by hospital staff was out of date, semi-frozen or the wrong product for the patient, a report revealed yesterday.

There were 144 cases of adverse reactions relating to the transfusion of blood and blood components last year, according to the 2001 annual report of the National Haemovigilance Office (NHO). Almost 50% of these related to the incorrect blood component or product being transfused.

The errors documented by the report for these 69 people include the product being misnamed in medical notes or a patient getting a blood product prescribed for someone else.

Other mistakes include frozen products not properly thawed, poor labelling of products, or out-of-date blood stock being issued in hospitals.

The side-effects of these errors can range from mild adverse reactions to death in very rare circumstances, often dependent on the patient's underlying illness. However, no one died last year from incorrect blood products.

Only 85 incidents were reported to the NHO in 2000, but the number of hospitals which reported incidents increased from 51 to 65 last year. The increase is also being attributed to better reporting procedures being encouraged among hospital staff.

While NHO director Dr Emer Lawlor said these findings were in line with international experience, she admitted the report was worrying.

"There is some cause for concern, but at least we now have evidence of the kind of mistakes being made to allow us develop systems for improvement," Dr Lawlor said. She said figures for this year will probably be higher again before reporting practices become more standardised.

While patient groups welcomed improving levels of reporting, they still find the rates of human error worrying. "One of the reasons is the inadequate training for medical staff in the use of blood products, which should be treated like gold dust," said Dr Tony O'Sullivan of Patient Focus.

Labour's health spokesperson Liz McManus was shocked at the scale of medical errors. "It's a symptom of a deeper malaise the money for the health service wasn't wisely spent and instead of frontline staff we have more administrators," she said.