Hospitals in developed places such as Hong Kong have long had effective systems in place to screen donated blood for bacteria and infectious diseases. But there remains a risk of contamination, however low, even when people donate their own blood ahead of surgery that might require a transfusion. The case of a Tuen Mun Hospital patient with chronic liver disease who received a transfusion of donated blood contaminated by bacteria is an unfortunate reminder.
The Health Authority has issued stringent operational guidelines for the administration of blood transfusions. The hospital's consultant microbiologist says initial investigations found that staff responsible for the transfusion had complied with them. Storage and transport also complied with safety guidelines. The Red Cross Blood Transfusion Service says the platelets would have been tested for bacteria and the bags used for storing it decontaminated. Yet preliminary findings showed Pseudomonas fluorescens bacteria in the patient's blood and in the donated blood. It is the first such case recorded in Hong Kong, although contaminated transfusions have resulted in other infections in the past.
Given that there was no apparent system or human failure, the incident on Thursday is a matter of serious concern. It is to be hoped the expert investigation already under way can get to the bottom of it. The risk needs to be put into perspective. The chances of bacterial contamination of blood, or of infection or death from transfusions, are very low. But precautions can only minimise the risks, not eliminate them. The leader of the investigation, University of Hong Kong microbiologist Yuen Kwok-yung, draws a parallel with surgery: even after sterilisation is complete, opening a wound on a patient introduces a risk of infection.
One of the first tasks Professor Yuen's team will tackle, before completing its investigation, will be to propose enhanced safety measures, including prompt action on patients suffering transfusion shock. It should also address a possible blood storage problem he identified - that if a low level of bacterial contamination escaped detection after donation, it might multiply at the temperature at which the blood is stored, sometimes for weeks.
The prompt, detailed disclosure of the incident by the Hospital Authority and the hospital concerned is to be welcomed. It is an example of a new policy of openness and transparency aimed at improving the quality of the authority's service. Under a three-step approach adopted in October, medical mistakes are supposed to be openly reported, their cause analysed and the lessons learned applied in all hospitals. This followed a spate of serious medical mishaps in public hospitals that showed a better approach was needed in dealing with such incidents. Without a time frame for acknowledging errors or their seriousness, such matters were often kept quiet, or leaked to the media by relatives.
Public health care in Hong Kong remains among the best in the world. Having a rigid reporting system ensures that all incidents are quickly recorded and made known so that all with a stake in our health system can strive to keep it that way. Meanwhile, it is reassuring that Professor Yuen says Hong Kong people should not lose confidence in the city's transfusion system because it remains one of the world's best, and he has promised to look into the smallest detail in an effort to minimise the already very low risk of bacterial contamination of donated blood.