Transfusion never events just ‘tip of iceberg’ at troubled trust
Fourteen never events recorded at University Hospitals Birmingham Foundation Trust’s transfusion service were the “tip of an iceberg”, an external review has concluded.
The Royal College of Physicians (RCP) investigation, obtained by HSJ, reveals the service saw more than 150 additional “adverse events” recorded in just three months.
The review of the service’s activities between 2019 and early 2023 also concluded there had been “inaction” at senior management level on addressing the problems and that there was a lack of understanding among senior leaders about the significance of the risks posed by the service.
The RCP report said it was unlikely the reviewed never events “comprised the totality” of transfusion errors by the service and concluded that they were in fact just the “tip of an iceberg” of the errors made by the service.
These included seven incidents of the wrong blood being stored in tubes and a patient “with childbearing potential” incorrectly transfused in accident and emergency with group O RhD positive blood. This risks the patient’s antibodies attacking a future unborn baby if the foetus is RhD positive.
ABO-incompatible blood transfusions have a potential for significant morbidity and mortality and are “wholly preventable”, according to NHS Blood and Transplant.
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Source: HSJ, 10 July 2024