Princess Margaret Hospital announces blood transfusion incident
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The spokesperson of Princess Margaret Hospital (PMH) made the following announcement today (April 6) regarding a blood transfusion incident:
A 63-year-old male patient who suffered from end-stage renal failure and required peritoneal dialysis was admitted to the medical ward this morning due to peritonitis. As the patient was diagnosed with anaemia, the attending doctor has arranged blood transfusion for him. Blood typing and screening was conducted according to established procedures and results showed that the blood type of the patient was O positive.
At around 11.45am, blood transfusion procedure was carried out by an Advanced Practice Nurse and a Registered Nurse after verification of the patient's identity. Two minutes later, the Registered Nurse was alerted by the infusion pump alarm and found that there was around 2 centimetres of air bubbles in the transfusion tubing. She then disconnected the tubing in an attempt of expelling the air bubbles but not successful. The blood transfusion procedure was stopped immediately and blood was not infused to the patient. Since the concerned Registered Nurse was engaged in preparing a medication round which would soon begin, she assigned another Registered Nurse to prepare a new set of transfusion tubing.
After taking over the preparation of the new transfusion tubing, the second Registered Nurse mistakenly connected the new tubing to another 70-year-old male patient staying at the adjacent bed. This patient also suffered from peritonitis but does not require blood transfusion. His blood type was AB positive and the blood transfusion procedure had started. Around five minutes later, the first Registered Nurse discovered the incident and stopped the transfusion immediately. It was estimated that less than 5 millilitres of blood had been transfused to the patient.
The doctor in-charge immediately attended the patient and confirmed all vital signs were normal. The patient is now in stable condition. In general, people with blood type as AB positive can receive blood types of A, B, O and AB. The hospital has explained the incident and extended apology to the patient's family. His condition will be closely monitored. The hospital will maintain close contact with the patient's family. The 63-year-old male patient who originally required blood transfusion had been provided with transfusion treatment subsequently and is now in stable condition.
The hospital is very concerned about the incident and has already reported to Hospital Authority Head Office (HAHO) via the Advance Incident Reporting System. A panel will be set up to investigate the incident. The report will be completed within eight weeks. Upon completion of the investigation, the hospital will explain the findings to the patient’s family and submit the report to HAHO.
Counselling has been provided to the concerned staff and the hospital has reminded the concerned department to enhance monitoring and remind all the frontline staff to strictly comply with the protocol and guidelines of blood transfusion procedure, including verification of patient's identity. Enhanced mentoring and provision of extra training courses on blood transfusion procedure to less experienced frontline nursing staff will be conducted within one month to prevent recurrence of similar events.
Ends/Thursday, April 6, 2017
Issued at HKT 20:50
Issued at HKT 20:50
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