Setting Up the Hemovigilance Scheme in Ireland

SUMMARy The international tragedy surrounding the infection of the blood supply by human immunodeficiency virus (HIV) in the 1980s, together with the recognition of the increasing morbidity associated with hepatitis C virus (HCV) and the accompanying paradigm shift in transfusion medicine led to the development of hemovigilance in a number of countries. In Ireland, the infection of women with HCV through anti-D immunoglobulin, and hemophilia patients with HIV and HCV from factor concentrates, ensured that hemovigilance would be adopted as a high priority. The hemovigilance system in Ireland was launched in October 1999 under the National Haemovigilance Office (NHO). In the initial stages of development, the possibility of drawing on the experience of two well-developed systems already in operation, SHOT and the French hemovigilance system, was a huge advantage. Reports are collected on an anonymous basis using similar, though not identical, categorization of incidents to the UK system. A key feature borrowed from the French hemovigilance scheme was the decision to appoint a Transfusion Safety Officer (TSO) in each hospital or group of smaller hospitals. The in-depth analysis of individual incidents, coupled with the review of incidents showing common features, generates recommendations to improve transfusion practice. By drawing attention to a systemic approach to eliminating error rather than by promoting a blame culture, the hemovigilance scheme has the capacity, if implemented appropriately, to improve overall patient safety which extends well beyond the transfusion process itself.