UK Experts Focus on Cutting Transfusion Mistakes
Wed Apr 30, 4:30 PM ET Add Health - Reuters to My Yahoo!
By Stephen Pincock
LONDON (Reuters Health) - By far the biggest health risk from blood transfusions in Britain continues to come from being given the wrong blood -- a problem that occurs once in every 25,000 units of blood transfused -- experts said on Wednesday.
Although Britain's national Serious Hazards of Transfusion (SHOT) program has reported for five years that transfusion of incorrect blood is the most common problem, there is no sign that headway is being made, said Dr. Hannah Cohen, chairperson of SHOT's steering committee. (
SHOT Report)
"What the numbers are telling us is that despite having patients getting the wrong blood and us reporting this for five years, we're still seeing it," Cohen told Reuters Health at a meeting organized by the Royal Society of Medicine and the British Blood Transfusion Society.
Blood can be incorrect for a patient if there is a type mismatch, if the blood is not properly treated prior to infusion (which is necessary for patients with certain conditions) or is incompatible for some other reason.
Between 1996 and 2001, approximately 17 million blood units were transfused in the UK, and there were 1,148 reports of adverse events, the SHOT reports show.
Of these, 60.9 percent, or 699 cases, were "wrong blood" incidents -- most of which originated with failures of bedside checking procedures. Eleven patients died as a result of being given the "wrong blood" and 60 patients suffered serious illness.
Over the time SHOT has been recording figures, the number of hospitals participating in the scheme has increased, reaching 92 percent last year. The number of adverse events reported also increased.
"The continuing increase in "wrong blood transfusion" incidents is likely to reflect increased user confidence in the scheme and consequently increased reporting," Cohen said. "From that point of view it's a good thing."
On the other hand, she said, "it highlights that after five years of SHOT reports, no effective measures have put in place to reduce the incidence of 'wrong blood transfusions'." They are probably still being under reported, she added.
On a national level there have been some positive steps toward tackling the issue, including the establishment of a National Blood Transfusion committee by the Chief Medical Officer, she said. And last year, a circular from the Department of Health sent to all hospitals made a series of recommendations, including suggesting that they set up a dedicated transfusion team to push forward change at the medical frontline.
"I think we need a lot more to be done at hospital level," Cohen said. "Staff need training to know what they're supposed to do as a lot of errors are made because people simply didn't know what they were supposed to do."
But how these specialist teams, and their dedicated staff, should be funded is an unanswered question. Cohen said this was something that those who commission healthcare services -- for example Primary Care Trusts -- needed to focus on.
SHOT has also called for the National Health Service to take a lead in developing computer technology that has the potential to minimise transfusion error.
At the meeting, delegates also talked about the need to prioritise transfusion problems on a national level. There was a feeling that other, less serious, concerns were sometimes emphasized too heavily.
One option for addressing this might be to broaden the representation on the national Committee for the Microbiological Safety of Blood and Tissues for Transplantation. This committee sets priorities for safety measures that should be taken in relation to microbiological issues.
"I think that if one could look at perhaps increasing representation onto that committee to include individuals from the national blood transfusion committee and from SHOT, then you could have a committee with an extended remit and therefore look globally at the issue," Cohen suggested.
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