Blood alert for hospital chiefs

ALL HOSPITALS are being asked to review their procedures for handling blood after a study revealed 169 cases in which errors had been made, putting patients at risk.

In 12 cases, patients died and in a further 39 suffered serious injury requiring treatment in intensive care or dialysis for kidney failure.

The findings are contained in the first annual report by the Serious Hazards of Transfusion group (Shot) set up by professional groups independently of the National Blood Service to monitor the safety of blood transfusion.

About 3 million blood transfusions are carried out each year, the vast majority without problems, but when problems do occur they tend to follow a pattern, the Shot committee said. The commonest error, accounting for almost half the cases, was a mix-up in which blood intended for one patient was given to another. Blood for transfusions has to be carefully matched to avoid triggering a serious reaction.

There have been a series of scares about the safety of blood for transfusion in the UK involving fears about possible contamination and transmission of viruses including HIV and hepatitis. The results of the Shot study revealed three cases of bacterial contamination - one because the donor's arm had not been properly cleaned - and five in which an infection was transmitted; hepatitis A, B and C, HIV and malaria.

Three of the infections, including that with HIV, occurred as a result of donations during the "window" period - after the donor had been infected but before it showed up in routine tests.

Dr Lorna Williamson, chair of the Shot working group, said new tests were being developed to reduce the window period during which infections were undetectable. "We are dealing with very rare events but it is important that hospitals are still vigilant," she said.