Serious negligence' found in two blood transfusion cases
By Ran Reznick, Haaretz Correspondent
Two patients in Sheba Medical Center, Tel Hashomer, were given wrong blood transfusions by mistake, and a senior Health Ministry official called it "a serious case of negligence." Giving the wrong blood to a patient is one of the worst mistakes that can happen in medical treatment. A week ago a committee headed by Professor Noga Mani, the manager of the blood bank at Hadassah Ein Kerem Hospital, was set up to investigate the two cases and examine the work procedures in Shiba's blood bank.
According to the hospital's internal inquiry, published here for the first time, the two cases at the end of November 2003 and at the beginning of December, involved a series of bad mistakes by workers at the Sheba blood bank, run by Dr. Mati Mendell. In both cases the patients' condition temporarily deteriorated and they suffered haemolysis - a breakdown of red blood cells that could lead to anaemia and jaundice. Sheba doctors said the patients' condition improved considerably a few days later.
Blood transfusion is one of the most common hospital procedures, but is also one of the most dangerous of routine medical procedures. Any mistake leading to giving the wrong blood type can cause serious harm and swift death.
In the past decade a number of patients have been injured or killed after getting the wrong blood type, after mistakes by doctors or nurses or some malfunction in hospital blood banks. There were cases at Haifa's Carmel Hospital, Tel Aviv's Ichilov Hospital, Kfar Sava's Meir Hospital, Sheba and others.
The comptroller of the Klalit Health Maintenance Organization, Adi Shavit, examined the blood transfusion procedures in the HMO's seven hospitals and found many flaws. Among other things he found that between 1997 and 2002, 87 cases of mistakes and malfunctions in blood transfusions were reported, and in some cases the malfunctions recurred in the same departments, or at the hands of the same doctors. This was reported in Haaretz last September.
Shavit concluded: "Blood transfusions can save life but also endanger it. If a patient is given the wrong blood type, or if the blood has not been inspected properly from the stage of taking the blood sample to the transfusion... it could endanger the patients and even cause fatal damage."
In the first of the two recent cases in Sheba, on November 24, 2003, a patient was given the wrong blood transfusion. The technician on duty was aware of the patient's blood type, and that the patient was to receive blood without antigen type C, but "for an unexplained, incomprehensible reason" this information was not written on the blood bag, and the worker who brought it assumed that it had been checked and was found suitable.
Following this case "the unequivocal regulation to reexamine any unmarked blood portion was refreshed," the report said.
In the second case, on December 1 2003, a 58 year old leukemia patient received the wrong blood in the ward for transplanting bone marrow. In this case the blood bank technician picked out the wrong blood - which contained E-positive type instead of E-negative - the inquiry report said.
The technician found it difficult to explain the mistake and said she worked systematically and according to the instructions, the report said. The report said that Dr. Mendell decided to relieve the technician's work load and assigned her to simpler tests.
