http://212.2.162.45/news/iestory.asp...n=117433871289
Transfusion errors put 62 lives at risk


By Juno McEnroe
MISTAKES in blood transfusions resulted in 62 incidents which were life- threatening or could have caused permanent damage to the patient, a report to be published next month reveals.
The 150-page report, by the country's blood transfusion watchdog, recommends increased vigilance after serious errors were uncovered, including:

Transfusing the wrong blood.

Using blood that was badly stored or handled.

Giving mistaken blood test results.

Giving blood plasma to patients when it was inappropriate.

The report, by the National Haemovigilance Office (NHO), reveals that blood packs were removed from refrigerators, opened and then returned.

Strict medical regulations direct that blood packs, once opened, must be used within four hours or disposed of. In one case, 'spiked' blood units had been left open for 24 hours.

These units were transfused into patients.

There were 180 reported mistakes transfusing blood in 2003. Up to 62 were considered "severe" that is, life-threatening or with the potential to cause permanent damage.

NHO director Dr Emer Lawlor warns doctors in today's Irish Medical Times that they can expect criminal cases to arise from transfusion mistakes.

One of the worst mistakes in Dr Lawlor's annual summary includes the failure to supply anti-D blood product for a pregnancy, which can have harmful consequences for a newborn.

Dr Lawlor's report states: "These incidents highlight errors and high-risk areas in the work process, providing an important opportunity to effect improvements in practice and the overall quality of care for patients in the context of a no-blame culture."

__________________
Mr. Jan B. Wade
Blood Management Consultant
Enhance Outcomes - Control Cost
For Information Call - 360 296-1807
Email