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Call for national body to ensure blood transfusion safety

BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7135.881f (Published 21 March 1998) Cite this as: BMJ 1998;316:881
  1. Zosia Kmietowicz
  1. London

    Doctors in Britain concerned about the safety of blood transfusions have called for a national unified body to be established that will oversee the whole process, from collection of blood from donors to the delivery of blood components to patients on wards.

    The move follows the first annual report issued by the Serious Hazards of Transfusion (SHOT) scheme, which revealed that in the year ending September 1997, 94 hospitals reported a total of 169 instances of error, almost half (47%) of which were cases where patients had received a blood component intended for someone else. These resulted in one death and nine cases of major morbidity.

    Analysis of the errors shows that mistakes were made at all stages of the transfusion process. There were 21 cases of laboratory error (incorrect grouping or crossmatching (13 cases), mislabelling (3), and selection of the wrong component (5)). More than half (54%) of the errors occurred at the collection or administration stages, while misidentifying the patient at the time of the transfusion accounted for four errors. In one case a blood component was given to a patient who had not been prescribed it.

    Dr Hannah Cohen, chairwoman of the SHOT scheme and senior lecturer in haematology at St Mary's Hospital in London, said: “Considering there are two million units of blood issued each year, the rate of complications is very small.” She added, however, that the survey identified areas where the safety of transfusions can be improved and procedures need to be tightened. “All hospitals should review their local system and procedures for transfusions and ensure that all staff handling blood are fully aware of procedures for that hospital and that they receive appropriate training,” said Dr Cohen.

    The British Committee for Standards in Haematology is currently working on setting new national standards for uniform best practice in the collection, delivery, and monitoring of blood transfusions. Ultimately, however, Dr Cohen hopes that a unified body will be formed to take overall responsibility for transfusion safety. “Currently there are several organisations which produce recommendations and guidelines. The Transfusion Service, the hospital blood bank, phlebotomy department, and portering and nursing staff are all involved in transfusions, but the regulation and training of these bodies of staff is disparate. A unified body could set priorities and direct resources for maximum patient benefit,” she said.

    The SHOT scheme's annual national survey was launched in November 1996 with the aim of documenting all the major complications of blood transfusion in the United Kingdom to improve safety. The system is voluntary, and out of 424 eligible hospitals, 94 responded in this the first year. SHOT's steering committee comprises representation from eight royal colleges and six other professional bodies. It became affiliated to the Royal College of Pathologists on 21 November 1997.


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