National Haemovigilance Office 2001 Report

The National Haemovigilance Office (NHO) 2001 Annual Report was launched today (Sunday) at the National Blood Centre, in Dublin. Speaking at the launch, the Acting CEO of the Irish Blood Transfusion Service Andy Kelly said that he was pleased to be launching the second Annual Report of the NHO, covering the period 1 January 2001 to 31 December 2001.

"Overall, the Report's findings illustrate that blood transfusion therapy is a relatively safe procedure, with the majority of transfusions given within extremely high standards of care. Through the reports recommendations, the further development and improvement of transfusion guidelines for hospitals is supported. The operation of the haemovigilance system is an excellent example of how close collaboration between the IBTS and the clinical, nursing and laboratory staff in hospitals can benefit patient care," he added.

Dr Emer Lawlor, Director of the NHO said that the anonymised, no blame culture, focusing on system failure rather than personal failure, was a central tenet of any haemovigilance scheme, and was supported by the leading experts in the field of medical error.

"Serious adverse events are rare, especially when compared to the large number of transfusions given in Irish hospitals. However, when adverse events and/or errors do occur, this highlights the effects for patients, together with the concern and distress of the professional caregivers involved. The scheme reduces the likelihood of such events and errors being repeated in the future.

"The NHO encourages and actively supports the development of hospital in-service training programmes for nurses and laboratory staff by working closely with hospital based TSO. The office also encourages the development of audit functions at hospital level in an effort to promote best transfusion practice. Copies of the NHO Report and its recommendations for improved practice are being circulated to all Hospital Transfusion Committees.

"One hundred and forty four cases of adverse events/reactions relating to the transfusion of blood and blood components were reported to the National Haemovigilance Office (NHO) in 2001.

"In total, 77% of hospitals participated in the scheme this year, which represented an improvement of 9% on participation figures for the year 2000. This increased participation was anticipated and is attributed to increased vigilance and awareness of the national haemovigilance programme by healthcare professionals.

"The ongoing and increasing support of staff in hospitals around the country, particularly for the TSO, transfusion laboratory staff and Consultant Haematologists, demonstrates an enthusiastic attitude towards haemovigilance in Ireland, and provides a firm basis for achieving improvements in the standard of care for transfusion patients. The potential benefits for all concerned are tremendous particularly in preventing harm and also in providing an environment that permits the delivery of an improved quality of care for all patients.

"During 2001, over 163,000 units of red cells, platelets, FFP and cryoprecipitate were issued and the vast majority of these transfusions proceeded without incident. It is important to remember that patients would be unable to benefit from many forms of surgery, cancer treatment or transplantation without the availability of blood transfusion.

"In the first two years of the operation of this Scheme, the largest number of reports received by the NHO has been in the category of Incorrect Blood Component Transfused (IBCT). This is very much in line with international findings and provides scope and opportunities for improvements in clinical practice. Finding the root causes of error is the most important aspect of the evaluation of these incidents, as without an adequate understanding of theses causes, there is little likelihood the system can be improved and the error prevented in the future.

"I wish to particularly acknowledge the support and efforts of the staff of the NHO in promoting best practice as well as researching and compiling the necessary data for the drafting of this report. As a Service, we are acutely aware of the debt owed to the thousands of voluntary blood donors who donate every year," said Dr Lawlor.