First Annual National Haemovigilance Office Report Published
Eighty-Five cases of adverse reactions relating to the transfusion of blood and blood components were reported to the National Haemovigilance (NHO) in 2000 according to its first Annual Report. In total, 51 hospitals participated in the system using approximately 135,000 units, accounting for 70% of all blood components used in the past year. Seventy-seven hospitals participated in training and education seminars conducted by the NHO in 2000. The NHO has a two-fold function: collecting and analysing reports from hospitals and healthcare workers of adverse reactions relating to the transfusion of blood components and the organisation of training and education programmes for hospital staff.
Commenting on the National Haemovigilance Offices first Annual Report Dr. Emer Lawlor, Director of the NHO said she was extremely pleased with the level of participation by hospitals in the haemovigilance system. "Hospital based Transfusion Surveillance Officers, Consultant Haematologists and laboratory staff are integral to ensuring that this system works and they need to be able to do this in a no-blame scenario. Otherwise errors may not be highlighted and mistakes could continue. This system ensures that the principle of best practice pervades and that we can all learn from each other and work together to ensure the transfusion chain is as safe as it possibly can be." Copies of the NHO Report and its recommendations for improved practice are being circulated to all Hospital Transfusion Committees.
According to Dr. Lawlor, an incorrect blood component was transfused in 31 of the 85 reported cases highlighting the need for strict checking procedures to be applied in all aspects of the transfusion chain from blood bank to patient. This mirrors evidence recorded by similar haemovigilance systems in countries such as the UK
A severe anaphylactic or severe acute transfusion reaction was recorded in 36 incidents. Most cases concerning anaphylactic reaction involved the transfusion of Fresh Frozen Plasma emphasising the need to only transfuse Fresh Frozen Plasma when clinically indicated.
In eight cases, volume overload was recorded particularly in very young or elderly patients or patients with cardiac or respiratory problems. This emphasises that careful attention should be paid to these patients fluid balance prior to transfusion and infusion should be administered slowly. While there were no incidents reported of transfusion transmitted bacterial infection, there were a possible seven incidents reported where hospitals suspected transfusion transmitted infection. After investigation by the NHO, four incidents have been ruled out, two are currently under investigation while one case cannot definitively be ruled out.
The Reports finding illustrates that while blood transfusion therapy is a safe procedure, there is still a need to develop and perfect systems to ensure safety and to eliminate errors in all stages of the transfusion chain. Primary areas of concern are those incidents which provide opportunities for improved practice, therefore the categories of Incorrect Blood Component Transfused and Transfusion Related Circulatory Overload are of particular interest.