Hospitals across the State have admitted to a catalogue of errors in the way in which they transfused blood products to patients over the last year.
The errors resulted in the death of one patient and "contributed" to the death of another, a new report reveals. In one case the error occurred when a patient who was hospitalised was treated using a different patient's records.
The report states there were 180 transfusion-associated adverse events reported by hospitals in 2003. Some 62 of these were life threatening or had the potential to cause permanent injury.
The hospitals where these occurred are not named in the report. The mistakes ranged from patients getting the wrong type of blood to receiving too much blood.
Details of the mistakes are chronicled in the latest annual report from the National Haemovigilance Office, which is located at the headquarters of the Irish Blood Transfusion Service in Dublin.
The office collates and follows up reports of adverse events relating to the transfusion of blood and blood components at 81 Irish hospitals.
The majority of adverse incidents related to incorrect blood components or products being transfused. This happened on 115 occasions, according to the report.
Several factors were blamed for the errors. These included communications failures between medical and laboratory staff and basing transfusions on "inaccurate or old haematology results". Some errors occurred at night when laboratory scientists, not normally working in transfusion, provided cross-call cover.
Some 11 patients got unnecessary transfusions "due to erroneous prescriptions". Three patients suffered adverse reactions after receiving red cells which had been left out of a fridge for longer than the recommended time and were "then returned to the fridge and later transfused".
There were 14 cases where transfusions resulted in circulatory overload. One of the patients affected was being given solvent detergent plasma to reverse the effects of warfarin which thins the blood. "Although the patient was very ill before the transfusion, it is likely that the transfusion contributed to mortality," the report said.
In another case a platelet transfusion resulted in a case of Transfusion Related Acute Lung Injury (TRALI). The patient affected died. "Based on the close temporal association of symptom onset with the transfusion, the clinical picture and the post-mortem features, it was felt that this fatality was very likely to be due to TRALI," the report added.
The report includes a number of recommendations aimed at preventing the errors recurring.