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The following is issued on behalf of the Hospital Authority:
The spokesperson of Tuen Mun Hospital (TMH) today (January 6) announced a rare, major blood transfusion reaction event:
A 52-year-old male patient who has been suffering from chronic liver disease and anemia was admitted to the medical ward of TMH for blood transfusion (red cell) on January 3, 2008. After two hours of transfusion, the patient developed shock and severe shortness of breath and had drop in blood pressure. Transfusion was stopped immediately and appropriate treatment was given at once in the ward, including oxygen therapy and intravenous injection of anti-allergy medicine. The patient was transferred to Intensive Care Unit for further treatment.
The patient is now in critical condition and undergoing intensive treatment and monitoring in ICU. The doctor has given detailed explanation to the patient's family about the transfusion reaction event. The hospital expressed deep sympathy to the patient and his family.
Laboratory tests were carried out on the concerned packed blood. Preliminary findings show that Pseudomonas Fluorescens was isolated in the bag of blood and in the patient's blood. Further clinical tests of the blood sample will be conducted. The hospital has confirmed that the staff who initiated the transfusion had complied with the stringent transfusion protocol and guidelines when carrying out the procedures for the patient. In addition, the hospital has examined the blood storing in the blood blank, the storage time and limit, and the transport arrangement. It is confirmed that all the above comply with the safety guidelines.
The departments concerned immediately reported the case to the hospital management and Hospital Authority Head Office (HAHO). The hospital has set up a expert panel chaired by Professor K Y Yuen of Hong Kong University, with members including Dr Y M Yeung, Consultant, hematologist of Tuen Mun Hospital, Dr Raymond Chu, member of Hospital Authority (Blood Transfusion Service) Expert Panel on Blood and Blood Products Safety, and Dr W C TSOI, Associate Consultant, Hong Kong Red Cross Blood Transfusion Service. The investigation report would be submitted to HAHO.
This is a rare blood transfusion reaction case in Hong Kong. Investigation findings shown that the incident involved no staff or system error. According to international literature, there is a risk in blood transfusion process, despite it is very low, especially bacterial infection in red blood cell. According to medical literature, the probability of red blood cell contamination ranges from 1 in 30,000 to 1 in 50,000; while transfusion reaction by contaminated red blood cell is about 1 in 500,000, in which the mortality rate is 1 in 1,000,000.
All public hospitals and staff have already been reminded on strict compliance of the operational procedures for transfusion. BTS is very concerned about the incident and will re-examine the procedures of blood collection, screening and dispatching as well as reminding all the frontline staff to strictly observe the transfusion guidelines and report all irregularities found.
The Blood Transfusion Service (BTS) stresses that there is a stringent blood collection procedures, including the selection of donor, the decontamination procedures for the donor before the collection of blood, the examination of the initial 30 ml of blood collected and the conduction of bacteria test for the platelet. Furthermore, BTS has executed quality blood management system; all the bags used for storing the blood collected had been decontaminated.
Ends/Sunday, January 6, 2008
Issued at HKT 17:00
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