Review calls for improved patient identification systems for bloodBMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7185.692 (Published 13 March 1999) Cite this as: BMJ 1999;318:692
Unique patient identification systems are being recommended in a report from a steering group of all professions involved in blood transfusion in the British Isles, in response to a review showing increased reports of incidents involving incorrect components being transfused.
The Serious Hazards of Transfusion group–which includes representatives from eight Royal Colleges plus other professional bodies–has suggested that funding should be provided to evaluate and develop computerised blood issue and innovative patient identification systems to improve patient safety.
The recommendation has been made in the group's annual report published this week, after 112 hospitals in a voluntary survey of 424 hospitals reported a total of 197 adverse incidents involving blood transfusion for the year ending September 1998. Most of these (110 cases) were described as “wrong blood to patient” incidents, representing an increase from the previous year's 81 incidents.
The participating hospitals reported nine deaths directly attributable to all complications of blood transfusion, and 42 cases of major morbidity. Two deaths were attributed to patients having been given the wrong blood.
The weakest link in the transfusion process seemed to occur when blood was taken from a hospital blood bank refrigerator, with the incorrect type being taken and then transfused into a patient without further checking.
The number of errors was small in relation to the total numbers of transfusions carried out, with the UK Transfusion Service preparing around 3.5 million items of blood components each year. But giving patients the wrong type of blood was by far the largest hazard. Infection associated with transfusion was a much smaller problem, with 26 suspected cases being reported.
Dr Williamson suggested that a system of bar codes could be introduced–for a patient's blood type and for blood products.
Serious Hazards of Transfusion Annual Report (1991-1998) is available from the Serious Hazards of Transfusion Office, Manchester Blood Centre, Plymouth Grove, Manchester M13 9LL, price £20 (cheques payable to National Blood Service, Northern Zone–SHOT).