Blood transfusion errors revealed

AN error during a blood transfusion may have caused the death of an elderly patient, a report has revealed.

An investigation by the Irish Blood Transfusion Service (IBTS) also found 87 patients received incorrect blood components during transfusions last year.

Of the 87 cases of errors identified in the report, 41 had the potential to cause permanent injury. A further analysis revealed that 46 errors could have been detected and prevented during the final bed-checking procedure.

Errors of this type, while rare in Irish hospitals, were responsible for more than half of all transfusion-related incidents investigated by the Irish Blood Transfusion Service (IBTS) in 2002.

IBTS acting chief executive, Andy Kelly, said the report’s findings showed that blood transfusion therapy was still a “relatively safe” procedure.

The blood bank cannot stay “completely safe” because there is no such thing as risk-free transfusion.

Launching the 2002 report of the National Haemovigilance Office (NHO) Mr Kelly said it was the third year of the scheme in which over 90% of hospitals are now involved.

NHO director, Dr Emer Lawlor, said the focus should be on system failure rather than personal failure.

“There is a need for hospitals to invest in up-to-date patient record systems, in automated technology for patient identification, blood sampling and administration and to have ready computer access to laboratory results,” she pointed out.

During 2002, over 168,000 units of red cells, platelets, plasma and crycoprecipate (clotting agent) were issued, with adverse events or reactions reported in 155 cases.

Dr Lawlor said the transfusion of an inappropriately large number of red cell units might have contributed to the death of the elderly patient.

While hospitals will be obliged by law to report adverse reactions to transfusions from February 2005 they will not be obliged to report errors, added Dr Lawlor. She said the statistics were very much in line with international findings.