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October 30, 2013

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Fear stopping blood error reporting

CITY hospitals are not reporting blood transfusions errors for fear of being punished for mistakes, the head of Shanghai’s blood service said yesterday.

A better monitoring system and improved administration are required to get a more accurate picture, said Zhu Yongming, director of the Shanghai Blood Center.

“In line with international practice, we want to build a monitoring system from ‘vein to vein’ — from donor to recipient,” said Zhu, speaking at the China-World Health Organization Haemovigilance Consultation in the city.

“Incidents should be defined and reported for data collection and assessment,” added Zhu.

Delegates heard that on average, Shanghai’s blood center received fewer than 10 reports of adverse reactions a year.

This is far lower than Western countries with well-established monitoring systems.

In Britain, some 1,800 serious blood-related accidents were reported in 2011.

Of these, about 5 percent of accidents involved patients given the wrong blood. And of those, 85 percent were due to medical staff errors.

To improve blood safety, Shanghai is establishing a citywide surveillance system covering the entire process of blood collection, transfusion and use. Already, some hospitals are running the system.

Zhu said a culture needs to be created where staff feel they can report errors without fear of being punished.

“In the West, people are not blamed or punished for reporting a blood safety incident, as the authority that collects data and investigators who may uncover human error are different,” said Zhu.

“And most of the time, the error is not just down to one staff member but flaws in the system. In-time reporting can help expose and tackle these.”

Delegates also heard that in a bid to attract more young female blood donors, next year a blood collecting vehicle will feature popular Japanese cartoon character Hello Kitty, complete with souvenirs for donors.



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