Jaipur: A potentially fatal blood transfusion error was narrowly prevented at SMS Hospital after blood centre staff detected a mismatch in the blood group recorded for a 19-year-old patient admitted for surgery this week.The incident occurred on July 2, when a blood requisition form was submitted for patient Vinay Sharma, who wasadmitted on June 30 for a left total hip replacement. The blood sample attached to the requisition showed his blood group as B positive. Based on the request, blood bag number 22056 of B positive was being processed for issue.Before releasing the blood, staff at the department of immunohaematology and transfusion medicine, blood centre (ITMBC), SMS Hospital, checked the patient’s previous blood group record in the hospital computer system. The earlier record showed Sharma’s blood group as O positive. The discrepancy immediately raised suspicion of a “wrong blood in tube” case, commonly known as WBIT, where the sample submitted does not belong to the intended patient.The blood supply was withheld immediately. A fresh sample was collected from the patient and tested. The repeat test confirmed that Sharma’s correct blood group was O positive, not B positive. The timely check prevented a wrong blood transfusion, which could have caused a severe transfusion reaction and endangered the patient’s life.During the hospital’s inquiry, officials found that the ward mistakenly sent the blood sample of the patient’s father instead of the patient’s. In a written statement, the father, Pramod Sharma, a resident of Rajakheda in Dholpur, said his son was admitted for surgery and he went to the blood centre to donate blood for his son. At the counter, he was asked to bring a blood sample. Pramod returned to the ward and, by mistake, his own blood sample was collected and submitted at the counter.ITMBC in-charge Dr Devraj Arya said the hospital introduced standard operating procedures (SOPs) for safe blood transfusion a few months ago. “The SMS Hospital implemented SOPs for safe blood transfusion a few months ago. We are now ensuring blood safety from donor’s vein to patient’s vein by implementing blood safety SOPs,” Dr Arya told TOI. He added the system now focuses on ensuring blood safety from the donor’s vein to the patient’s vein through strict implementation of transfusion safety protocols.The blood centre’s intervention is significant because SMS Hospital has previously reported cases of wrong transfusions, including incidents that proved fatal for patients. In the past two years, govt hospitals in the state have reported at least five wrong blood transfusions. A day earlier, the office of Jaipur’s chief medical and health officer had misstated the blood group of former Vice President Jagdeep Dhankhar, who was undergoing treatment at a private hospital, in its communication to the SMS Hospital. The error was later spotted and rectified. Thankfully, Dhankhar did not require blood transfusion.
