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Queen Elizabeth Hospital announces a blood storage incident

The following is issued on behalf of the Hospital Authority:

     The spokesperson for Queen Elizabeth Hospital (QEH) made the following announcement today (October 7) on a blood storage incident:

     Queen Elizabeth Hospital's Pathology Department has a cold room that stores reserve blood units. The optimal temperature for storage is 2 degrees to 6 degrees Celsius. Apart from the cold room's own temperature sensor, the department has also installed an external 24-hour "Computerised Temperature Monitoring System". The system would issue a warning when the temperature of the cold room exceeds the optimal range to ensure blood storage safety.

     At about 3am yesterday (October 6), the "Computerised Temperature Monitoring System" triggered its alarm system which illustrated that the temperature of the cold room was above 5.5 degrees Celsius. A staff member of the Pathology Department entered the cold room to conduct an inspection and enhance monitoring. At about 5am, the staff inspected the cold room again and found out that the temperature shown by the thermometer inside the cold room was 7 degrees Celsius. However, the alarm connected to the cold room's temperature sensor did not go off at that time. The staff member immediately alerted staff of the Electrical and Mechanical Services Department to carry a repair on site, which found that both the cooling and alarm system of the cold room were in malfunction. The temperature of the cold room later dropped to the optimal level after the repair but the blood units were not removed to other storage facilities.

     The department subsequently reviewed the data of the external "Computerised Temperature Monitoring System" and found that the temperature of the cold room was at 6 degrees to 8.4 degrees Celsius from 4am to 6am that day, which exceeded the optimal temperature range for blood storage. A total of 67 bags of reserve blood were stored in the cold room at that time. After consulting the Red Cross Blood Transfusion Service and haematologists, the hospital decided to suspend the use of the affected blood units on patients for the sake of patient safety.

     QEH expresses deep apology to the public and blood donors. The hospital had liaised with the Red Cross Blood Transfusion Service and would contact the 67 blood donors to offer an apology and explanation. The Pathology Department has reported to the hospital management and Hospital Authority Head Office (HAHO) via "Advance Incident Reporting System". QEH is highly concerned about the incident, and will seriously follow up and conduct an investigation to prevent similar incidents from happening again. The investigation will be completed in six to eight weeks and the report will be submitted to the HAHO.

     QEH had promptly enhanced improvement measures, including reminding staff to strictly comply with standard working procedures and checking up all cold storage equipment to guarantee their normal operation.

Ends/Tuesday, October 7, 2014
Issued at HKT 20:59


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