The number of patients being transfused unnecessarily with blood and blood components in hospitals across the State is rising and is a cause for concern, according to an official report published yesterday.
The National Haemovigilance Office's annual report states that in two cases in 2005 - the latest year for which data is available - the transfusions may have contributed to the deaths of two patients. In one of these cases the patient's circulatory system became overloaded with a transfusion which was unnecessary.
Dr Emer Lawlor, director of the Blood Banks's NHO, emphasised that the two patients were already very ill before they were transfused: "If they hadn't got the transfusion, they might have died anyway, but our feeling was that it probably didn't help."
Dr Lawlor said that the emergence of infectious diseases such as vCJD and West Nile Virus as new transfusion risks emphasised the need to avoid unnecessary transfusions. "Somebody should not be getting a transfusion they do not need," she added.
There were several explanations for transfusions being given unnecessarily, she said. These included "errors in clinical decision-making", the use of incorrect or outdated laboratory results and blood samples being wrongly taken.
For example, in one case highlighted in the report, a patient was transfused in error after a phlebotomist took a blood sample from the wrong patient. "The correct patient identification procedure was not performed, as the patient was not asked to identify himself, nor was the ID wristband checked," it said.
The error resulted in 300mls of red cells being given to the wrong patient, but with no adverse consequences, as both patients had the same blood type.
The report said that 40 transfusions given in 2005 were considered unnecessary. In five of the cases, anti-D was given in error to women who did not require it. In one of these cases a medical scientist who did not normally work in transfusion was processing a number of samples out of hours and mixed up two different samples.
The report says that, overall, 49 out of 83 hospitals transfusing blood reported 266 serious adverse reactions to transfusions in 2005, a 24 per cent increase on the previous year.
Dr Lawlor said that the increase was likely to be the result of increased reporting rather than a real increase in adverse events.
"In two of the cases involving reactions to apheresis platelets the transfusion was considered unnecessary, as it was given for an erroneously low platelet count based on a telephone message in one case and in the second case the prescriber had not checked the most recent platelet count prior to transfusion," the report said.
It pointed out that the transfusion of incorrect blood components accounted for 65 per cent of all the adverse incidents reported in 2005.
Looking at the reasons for these incidents, the report says that some of the errors originated in hospital laboratories, where a patient's blood test results were read wrongly or "misinterpreted". There were also "failures in communication between the transfusion centre and the hospital laboratory, between the transfusion laboratory staff and on-call laboratory staff, or between the ward and the laboratory", which led to the issuing to patients of wrong blood components.
In one case the wrong component was given when the hospital ran out of the correct type, but the report emphasised that there were "no fatalities or major morbidity associated with any of these transfusions".
Dr Lawlor said that the adverse reporting system was about stopping mistakes being repeated. The system improved patient safety, she insisted.