The IBTS can confirm that blood products were marginally over-irradiated at its Cork centre from 1st August to 3rd December, 2003.
This was detected during an inspection by the Irish Medical Board (IMB) at the Munster Regional Transfusion Centre (MRTC) which took place between 3rd and 5th of December, 2003. The board of the IBTS were extremely concerned and responded immediately to the IMB findings and have continued to keep this situation under constant review.
A further problem was identified during an internal review on 26th April, 2004, and this established that blood products may have been marginally under-irradiated from 5th December, 2003 to 26th April, 2004. The IMB were immediately informed and conducted inspections at MRTC on 17th and 18th May, 2004. Arising from this inspection report, the board of the IMB requested its chief executive to seek an urgent meeting with the chairperson, chief executive, and appropriate senior management of the IBTS to discuss this issue. At that meeting on 21st May, the steps being undertaken by the IBTS in relation to the management and operation of the irradiator were outlined to the IMB.
While the IMB were satisfied with these measures presented, they requested that a follow-up clinical review be carried out by the IBTS on all units affected. A special board meeting was held on 31st May to brief board members on the outcome of the meeting with the IMB and the steps agreed.
In line with our established procedures where a question arises over an issued product, all relevant hospitals and clinicians were notified of the review that was about to be undertaken. All the appropriate documentation with a questionnaire was circulated to all clinicians requesting a review of medical charts of all patients who had received irradiated blood between 1st August, 2003 and 26th April, 2004. Ninety-six per cent of the relevant medical charts have now been reviewed and no adverse events relating to the transfusion of irradiated blood occurred in any of those patients. As is normal practice, notification of patients is a matter for the treating physicians.
Risk analysis was immediately initiated on both incidents and steps have now been taken to ensure that such incidents will not reoccur.
The board of the IBTS viewed, and continues to view, these irradiation issues with the utmost seriousness and has responded accordingly. Our central concern as an organisation is patient safety and the board notes that there has been no detected negative impact on those who were administered these products.
We have worked with and will continue to work with IMB to ensure that such incidents will not reoccur. As the IBTS has a policy of not responding to any questions concerning individual staff members, it would be inappropriate to respond to your specific queries.
