‘Tip of the iceberg’ blood transfusion errors at Birmingham hospital trust

Blood transfusion errors in which cancer patients received the wrong type of blood on 14 occasions were just the “tip of the 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 last year.

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 needed greater attention.

UHB said it fully accepted the report’s findings and made significant improvements.

Birmingham and Solihull Integrated Care Board (ICB) called for the review of the blood transfusion service after seven “never events” – incidents that should never happen – were identified over four years at the trust between 2019 and 2023.

Five were identified at Queen Elizabeth Hospital, one at Good Hope Hospital and one at Heartlands.

There were two other errors involving a Heartlands patient in August 2023 before the review began.

The investigation found that one patient received six transfusions of the wrong blood type, making a total of 14 “never events”.

A meeting of the hospital transfusion group identified 156 adverse events that 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 became pregnant, and seven cases where the blood taken and put into tubes did not match the right patient.

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

UHB has previously undertaken its own safety reviews of events which never were, but in the latest, despite a deputy medical director, two consultants and a quality manager being involved, they repeated two recommendations that had been made in a previous report.

Staff also felt that management was not listening.

Dr Manos Nikolousis, who blew the whistle on previous fatal drug errors, said this exemplified the culture at the trust.

“I’m not sure how facilities can actually operate safely when all these events never happen in a highly specialized service,” he said.

Birmingham Edgbaston MP Preet Kaur Gill said she had already held meetings with new health secretary Wes Streeting about the trust.

“Red risks cannot be allowed to continue without any action and that is exactly what has happened,” she said. “That’s why we have the defects we’ve seen here.”

Ms Gill wanted the trust to show her the actions that had been taken and “how they are confident this will not happen again”.

The RCP report accepted that the merger of University Hospital and Birmingham Heartlands Group was a contributing factor to some of the earlier never-ending events.

Systems didn’t talk to each other, local autonomy was undermined, and staff were working in unfamiliar environments with different processes and protocols.

A UHB spokesman said patient safety was an “absolute priority” and it was working with staff to engage and educate them about safe transfusion practices.

The trust also improved its electronic patient record to ensure its laboratories had “clear information” and worked to consolidate and standardize processes across all its hospitals.

“There is still work to be done, but we have made progress and remain committed to ensuring that we eliminate the potential for transfusion-related events to never occur,” he added.