Blunders over blood transfusion killed 15 last year

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Indy Lifestyle Online

The number of cases of the wrong type of blood being given to hospital patients rose by 20 per cent last year, causing as many as 15 deaths and putting dozens of other people into intensive care.

But the group of health experts that collected the latest figures believes the true total could be twice as high, because half of hospitals reported no transfusion errors ­ a position seen as highly unlikely.

The mistakes were made despite repeated calls for simple technological systems such as barcodes to be used to prevent such errors. Such a system is only now being piloted in the North of England.

The latest report is from Serious Hazards of Transfusion (Shot), an independent group of clinicians inside the National Health Service formed in 1996 to collect data on serious effects from transfusions of blood and its components. It shows that in 2002 there were a total of 363 cases where people received the wrong blood component ­ which can lead to a deadly immune response ­ or caught infections through the transfusion. The report, Shot's sixth, shows that the total has risen steadily every year.

Dr Dorothy Stainsby, chairman of Shot, said: "The technology is there [to prevent errors]. There are systems in place, and not just for blood, but also to prevent errors such as the wrong limb being operated on. What's holding it back from being deployed is a correct recognition of the risk. Many hospitals will only see one of these events, and it isn't high on their list of things to act on."

Although there are 3.5 million transfusions each year, the rise in reported errors means that 1 in every 10,000 patients suffers such a mistake.

The most common cause of bad transfusions, Shot said, was that doctors or staff "collect the wrong [blood] unit from the refrigerator". It notes that this is most common during "out-of-hours" operation when staffing is low.

As well as the deaths and mis-transfusions requiring intensive care, three women of child-bearing age were given blood with the wrong "rhesus" component, which could be potentially deadly for their babies.

Compared with the 315 incidents in 2001, last year there was a 15 per cent rise in total incidents involving blood and components, such as infections carried in transfused blood. But there was a 20 per cent rise ­ from 213 to 258 ­ in the potentially lethal cases where the wrong sort of blood or its component was given. Shot also recorded a 7 per cent rise in "near misses", where potentially disastrous mistakes were spotted in time.

Reporting of incidents to Shot is voluntary, and kept anonymous. Even so, 191 of the 378 hospitals taking part in the scheme reported no incidents, which Shot says suggests "that incidents are passing unrecognised or unreported". Dr Hannah Cohen, a consultant haemotologist based at University College Hospital in London, who chairs Shot's steering group, told the Health Service Journal: "It is very undesirable that the wrong blood is going into patients because this problem is avoidable." She added that Shot "has no authority over implementation and cannot monitor compliance".

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