Secrecy on transfusion errors defended

Hospitals would probably not report mistakes they make when transfusing blood products if their names were going to be published…

Hospitals would probably not report mistakes they make when transfusing blood products if their names were going to be published, an official of the blood bank said yesterday.

Explaining why no hospitals were named in the annual report of the National Haemovigilance Office (NHO) published yesterday, its director, Dr Emer Lawlor, said the aim of the office was to catalogue adverse incidents, find out why they happened and learn from them, rather than being involved in a blame game.

Under this system hospitals reported 155 adverse incidents to the NHO last year.

Ninety-three per cent of Irish hospitals are participating in the surveillance system, and this figure is increasing year on year.

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It was felt when setting up the surveillance scheme, Dr Lawlor said, that if the hospitals were named they would be reluctant to report adverse incidents as people might then perceive them to be bad hospitals.

The NHO knew in which hospitals the adverse events were happening, but it shredded all the documentation it received from these hospitals once it had investigated them and had published its annual report.

"The importance of having a scheme where the information is anonymised is that it gets people to admit to mistakes from which they and other hospitals can learn," she said.

She added that a similar system with a no-blame culture operated in Britain, and the Netherlands was now following suit.