Letter: Transfusion errors

Transfusion errors

Sir: The inquest on the tragic death of Philip James (report, 10 October), due to confusion during a blood transfusion, highlights again weaknesses in the transfusion system in this country.

The recent report from the Serious Hazards of Transfusion (Shot) working group of the Royal College of Pathologists reported 81 cases of patients receiving blood components intended for another patient during 1996/97 from a total of 2.4 million units of blood transfused. The majority of these cases involved errors after the blood had been typed in the laboratory - collection of the incorrect blood bag (as happened in this case) and failure to confirm the identity of blood components and patient prior to transfusion. Reporting of similar cases is probably limited because they often come to light only when the patient reacts adversely to the transfused blood - even if the incorrect blood is administered only 35 per cent of the resulting transfusions will be incompatible and sometimes the patient will die from their presenting injuries or illness before incompatibility can manifest itself.

The Shot report recommends that the "bedside check is vital in preventing transfusion errors". In the UK this check consists of an identity check of the blood and the patient. In France and Germany, blood groups of the patient and blood component are checked at the bedside using rapid disposable test cards. This reduces the risk of administering the wrong blood type and also confirms the results from the laboratory (a source of 33 per cent of the errors). As more convenient and rapid bedside tests are becoming available, it is time that legislation is harmonised across Europe for the improvement of our health services.

Dr DAVID GROVES

Farnham, Surrey