Blood transfusion errors 'tip of iceberg' at trust, review finds

Blood transfusion errors where cancer patients were given the wrong type of blood on 14 occasions were just the "tip of an iceberg", a review has found.

More than 150 harmful incidents were identified within the blood transfusion group at University Hospitals Birmingham (UHB) trust between May and July 2023.

A report by the Royal College of Physicians (RCP) said the trust could not show evidence of a strong safety culture, and the blood transfusion service required greater attention.

The Birmingham and Solihull Integrated Care Board (ICB) requested the review of the blood transfusion service after seven "never events", incidents that should never happen, were identified during four years at the trust between 2019 and 2023.

Five had been identified at the Queen Elizabeth Hospital, one at Good Hope Hospital and one at Heartlands. There were also two further errors involving a patient at Heartlands in August 2023 before the review started.

The investigation discovered that one patient had received six wrong blood type transfusions, making a total of 14 “never events."

A Hospital Transfusion Group meeting identified 156 harmful events that had occurred in three months between May and July 2023.

These included a woman who was given rhesus positive blood which could harm a baby if she falls pregnant and seven cases where bloods taken and put into test tubes hadn't matched the right patient.

The report said: “The review team concluded that the seven never events were the tip of an iceberg, and that urgent attention must be given to the trust’s blood transfusion service to prevent patient harm.“

UHB, which has said that it fully accepts the report’s findings and has made significant improvements, had previously undertaken its own safety reviews of never events but in the last one, despite a deputy medical director, two consultants and a quality manager being involved, they repeated two recommendations that had been made in an earlier report.

Staff also felt that management was not listening.

Dr Manos Nikolousis who blew the whistle regarding earlier fatal drug errors, said that this exemplified the culture at the trust.

He said: “I'm not sure how units can actually operate safely when you have all these never events happening within a highly specialised service."

The RCP report accepted that the merger of University Hospital and Birmingham Heartlands Group had been a contributory factor to some of the earlier never events.

Systems were not talking to each other; local autonomy was undermined, and staff were working in unfamiliar settings with different processes and protocols.

A UHB spokesman said patient safety was an "absolute priority" and it had been working with staff to engage and educate them on safe transfusion practice.

The trust had also improved its electronic patient record to ensure its laboratories had "clear information" and had worked to strengthen and standardise processes across all its hospitals.

It added: “There is still work to be done, but we have made progress, and we remain committed to ensuring we eliminate the potential for transfusion-related never events occurring."