NEW safeguards are being urged to cut the number of hospital patients

who die because they are given the wrong blood transfusions.

Dr Brian McClelland, director of Edinburgh and South-East Scotland

Blood Transfusion Service, estimates that at least one blood transfusion

in every 550,000 has a fatal outcome because of such mistakes.

He and Ms Patricia Phillips, medical audit co-ordinator of the

Scottish Blood Transfusion Service, report in the British Medical

Journal today a survey they carried out over a two-year period in UK

hospital haematology departments.

In the study, 245 out of 400 laboratories responded.

A third of these reported a total of 111 incidents in which the wrong

blood was administered, resulting in six patients dying, and 12 others

suffering illness.

Dr McClelland said last night: ''That is not an alarming level and

doesn't suggest Britain is any worse than anywhere else. But we can't be

complacent.

''It is probably an underestimate, since it is unlikely that all the

other hospitals were error-free, and we would like a reporting system to

monitor and reduce the level of risk.''

This would preferably be a non-punitive system, like the near-miss

reporting system for pilots, to encourage people to be open about errors

and suggest ways they could be avoided, he said.

Most of the errors had occurred at the last stage, with the wrong type

of blood being picked up for a particular patient. Others involved the

wrong patient sample being put in the compatibility tube for matching

but there was no evidence of error in typing blood in the first place.

At worst, being given the wrong blood can result in the cells being

destroyed by the body's immune system, causing damage to the kidneys ;

or the clotting mechanism might be impaired, leading to serious bleeding

problems.

In practice, most of the errors reported had no ill-effects.

Only a third of unmatched transfusions are incompatible with ABO blood

groups, and a tenth of those are fatal.