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Reducible errors in blood transfusion?
- Joris Nauwelaers (26 April 2000)
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Joris Nauwelaers, General Practitioner B3990 Peer, Belgium
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EDITOR - “Blood is a juice of quality most rare”¹ ,was said by Mephistopheles in the first part of Goethe’s Faust. If it’s true that the devil, as was once believed, is often the cause of human errors and thus human misery, it is maybe possible that Goethe’s genius foresaw the problems laid bare by the SHOT-study, as was repeated in your correspondence columns ² of last week, and so that might be the reason why he put those words in Mephisto’s mouth… Because one of my patients was a victim of the kind of error they mention, this topic not only kept my attention, but also invited further pragmatic reflection. If I am correct I understood from the authors of the SHOT-report, that over a two year period there were 366 major problems in six million applications of blood products (including blood transfusions as prototype). Of these 366 major complications no less than 191 were due to human error, especially due to one patient erroneously being taken for another. So the foremost problem (more than half of all hazards!) is due to switching patients (because of the same name, same hospital room or department, or whatever – it’s a pity that no more details on this point were given). The grouping of indications (traumatology, post-operative, haematological pathology as eg. auto-immune haemolytic problems, palliative care) might have been mentioned, because I was wondering how many serious and possibly fatal problems occurred in patients who could be kept out of these error-inviting situations and so could have been totally prevented. As a clear-cut example of this preventable errors I would mention the case of young but active patients with metastasized cancer and intermittent heavy gastro-intestinal bleeding in whom blood transfusion is necessary to make them comfortable again because they are not yet terminal. (Let us hope that cancer patients in the future will not be excluded from blood transfusions in case of impending blood shortage...) If such a patient is treated in hospital he is candidate for becoming one of the 191 human errors. But, if the transfusion could be done by his General Practitioner at his surgery, or even at the patient's home, this risk is virtually non-existent. So I wonder how many patients (not postoperative, or acute trauma patients) of these 191 could have been saved this kind of error if the transfusion had been done out of hospital by an experienced and interested GP? (Blood sampling and cross-testing errors still being envisaged) One must not forget that the hazard of a major allergic reaction (anaphylaxis) due to penicillin has an incidence of 0.015 % to 0.04 % ³- clearly much higher than 191 or even 366 in 6 million… So transfusion risks in daily general practice are clearly less than eg. risks of uses of all kinds of medications as such. Why then, shouldn’t this be a task for GPs to lighten the burden of transfusion hazards from the major reasons expounded by the SHOT-study? They could take responsibility in avoiding these in-hospital risks for this group of patients (however small that is- even if there was only one) by not mistaking the patient for someone else.. Not forgetting the cost-saving for patient and for society in avoiding hospital care expenses, as well as the better patient satisfaction, which is equally -or maybe more- important. Joris F Nauwelaers, ¹ Transl. by Philip Wayne (Penguin Classics : Faust I, p. 89) – “Blut ist ein ganz besondrer Saft”-Goethe, Faust I, v1740 ² Williamson LM, Love E, Cohen H. Authors’ reply. BMJ 1999;320:1075.(15 april 2000) ³ Goodman L, Gilman A.- The Pharmacological Basis of Therapeutics (Macmillan -5th Ed) p. 1149 |
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