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Caritas Medical Centre releases investigation report on blood transfusion incident

The following is issued on behalf of the Hospital Authority:

     Caritas Medical Centre (CMC) today (November 9) released the investigation findings of a blood transfusion incident involving a 64-year-old female patient.

     The female patient was admitted on August 9 this year for elective surgical treatment of kypho-scoliosis and symptomatic spinal stenosis.  Pre-operative blood group typing and antibody screen test was performed on August 12.  She required a blood transfusion due to severe post-operative blood loss on August 15.  She was later suspected to be suffering from a left lower limb embolism and underwent an urgent embolectomy together with intravenous anticoagulation (heparin) therapy on August 16. Subsequent urgent computed tomography revealed that she had intra-cranial haemorrhage and she was transferred to Kwong Wah Hospital (KWH) for further treatment.  A repeated blood group typing test at KWH showed her blood group to be B instead of A as recorded by the laboratory of CMC earlier. CMC was informed immediately to follow up.

     CMC has subsequently set up an Investigation Panel to investigate the incident.  The Panel concluded that the incident was likely to be the result of errors involved in the analytical phase of the ABO/Rh(D) blood grouping procedure.  The first laboratory staff member probably wrote the blood group result of the female patient onto another patient's form and vice versa. As a result, her blood group result (Group B) was wrongly entered onto the other patient's laboratory form while the other patient's blood group result (Group A) was put onto her form.

     When the second laboratory staff member performed the independent checking tests for the two patients, the female patient's blood sample was probably put into test tubes labelled with the other patient's laboratory number and vice versa.  Hence, the results obtained were consistent with the inadvertently swapped results entered by the first laboratory staff member.  Consequently the female patient received a transfusion with two units of incompatible blood.  The other patient was not affected as a blood transfusion was not required.

     The Panel has identified the root causes of the incident as follows:

1. Inadequate understanding of the concept and practice of "Handle one specimen at one time, including checking patient and laboratory identifiers and subsequent processing" at critical control points of the Type and Screen procedure.

2. Insufficient continual supervision and systematic training to standardise and align practices among staff performing blood bank procedures.

     The Panel has made several recommendations to prevent recurrence of similar incident in the future:

1. Reinforce the concept and practice of "Handle one specimen at one time including checking patient and laboratory identifiers and subsequent processing" at specimen reception and at critical control points of the analytical process.

2. Arrange designated and experienced staff to provide continual supervision and training to staff working in the blood bank.
3. Re-examine workflow and standardise pre-transfusion testing process among staff.

4. Review existing standard operating procedures such that sufficiently explicit instructions are provided at specimen reception and critical control points to facilitate standardisation of practice, and are applicable to the workflow of CMC laboratory.

5. Reinforce independent interpretation of 1st and 2nd ABO/Rh(D) blood grouping result and proper documentation of responsible staff in essential steps of the Type and Screen procedure.

6. In the long run, consider the introduction of an automated blood bank analyzer with capability to interface with the Laboratory Information System.

7. Review workplace arrangements to facilitate a smooth and efficient workflow of the Core Laboratory.

8. Delineate clearly the roles, responsibilities and accountabilities of staff involved in all sections of the Core Laboratory Service.

     CMC is grateful to the Panel members for their comprehensive investigation and compilation of the report. The Hospital has submitted the report to the Hospital Authority Head Office and will follow up on the recommendations.

     Follow-up actions will be taken for the two staff members involved in accordance with established human resources procedures. The Hospital expresses its sincere apologies to the patient and her family for this unfortunate incident. The patient is still under the care of KWH.  CMC met the family today to explain the investigation findings and will maintain close contact with and provide necessary support to the family members.

Ends/Wednesday, November 9, 2011
Issued at HKT 17:40


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