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Two patients’ blood bags swapped at Pune’s Aundh hospital: How transfusion error can cause ‘kidney failure to death’

Mar 26,2024

PUNE: Two patients, including a senior citizen, undergoing treatment on beds next to each other at Aundh Civil Hospital were transfused with the wrong blood group, in a major mix-up on Saturday, landing both the patients in ICU.

Doctors said the patients did not show any major reaction and were under observation.

The patients, one suffering from anaemia (70+) and another (54) admitted with swelling in the stomach and limbs, were advised blood transfusion. While one has B+ blood group, another is A+, the hospital said.

Confirming the goof-up, civil surgeon at Aundh Civil Hospital Dr Nagnath Yempalle said, “The blood transfusion was stopped immediately after the patient aged above 70 complained of uneasiness. Preliminary report stated that the patient was recommended blood transfusion to boost immunity and increase haemoglobin count. The treating doctor checked both the patients thoroughly and mentioned their blood groups too before the transfusion. It has been brought to my notice that the nurse attending to the patients mistakenly switched the blood pouches at the time of transfusion.”

The civil surgeon said the mix-up, however, did not lead to any major ‘reaction’ in the two patients. “But we do accept that this is a major mistake. We have launched an enquiry into the issue and sent the nurse responsible on a forced leave. A three-member committee has been formed to look into the incident, findings of which will be submitted to the deputy director of health for further action.”

When contacted, deputy director of health services, Pune region, Dr Radhakishan Pawar said, “Strict action will be taken against those found guilty after the report is received from the hospital panel,” Dr Pawar said.

The relatives of the two patients alleged that the nurse was busy on her phone during the blood transfusion. Son of the 54-year-old patient told TOI, “My dad was admitted to the hospital on Thursday for swelling in the stomach and limbs. We were told on Saturday that he would be discharged from the hospital the next day. However, while the blood transfusion was underway, the relative of the patient (70+) occupying bed next to my father’s happened to notice wrong name on the blood pouch and raised an alarm. My father and the other patient were then immediately shifted to the ICU.”

He said the doctors told him that his father was stable and the other patient was passing blood in the urine. “The nurse was busy on her phone during the transfusion, resulting in the swapping of the blood pouches. My father will be under observation for 72 hours for any signs of reaction. So, it will be only by Tuesday evening that we will know the exact health status,” the son said.

According to experts, if the recipient’s body is transfused with the wrong blood type reaction can occur in the recipient about 24 hours after receiving the blood or may occur during blood transfusion.

Dr Ameet Dravid, infectious disease specialist at Noble Hospital, said, “The blood is grouped into A, B, O and AB types, which are either either RH negative or positive. While O+ is a universal donor, AB+ is a universal recipient irrespective of the RH type.”

He said if an A+ person is given a B+ blood group, it can lead to haemolysis, a process wherein the body’s immune system begins to attack the red blood cells perceiving them as ‘foreign objects’. “This can further result in reactions as serious as kidney shutdown or liver shutdown or even death. The consequences can be serious, especially when the patient is already weak. In such a case, the first thing to do is to stop the transfusion immediately and shift the patient to the ICU. The patient can then be provided with steroids to calm down the immune system,” Dr Dravid said.

On Saturday, MLA Ashwini Jagtap also visited the hospital and enquired about the health of the patients. She directed the administration to take strictest action against those found guilty.

Source: Healthworld

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