Taking serious note of the shocking neglect that led to infected blood being given to two patients and a mismatched blood transfusion to a teenager at the Blood Bank at the Civil Hospital Phagwara, Punjab Chief Minister on Friday ordered a detailed inquiry into the incident and immediate inspection of all the blood banks in the state.
The order came in the wake of media reports of two blood units infected with HCV & HbsAg being issued to two patients in Phagwara.
The blood bank at Phagwara has since been shut down and the concerned BTO Dr. Hardeep Singh Sethi has been placed under suspension. The contract of LT Ravi Paul has also been suspended, according to an official spokesperson, who further revealed that Dr. Kamal Kishore, SMO, had also been suspended and Civil Surgeon Kapurthala has been asked to file a criminal complaint with the Police Department for getting an FIR registered for criminal negligence.
Expressing grave concern over the matter, the Chief Minister has directed the Health Department to immediately undertake a thorough check of all the blood banks to ensure that the most stringent parameters of management were being followed there. No laxity in this regard could be permitted, he said.
On the Chief Minister’s directives, all blood banks in the Kapurthala district will be inspected by the District Blood Transfusion Committee headed by the Civil Surgeons within the next three days. Further, in addition to other periodic inspections, as a one-time measure, all Government Blood Banks will be inspected in the next 15 days and private Blood Bank will be inspected by March 31, by teams of Food & Drug Administration and Punjab Blood and transfusion Council.
It has also been noticed that District Transfusion Committees are not inspecting the Blood Bank periodically. Civil Surgeons have now been instructed to ensure inspections of Blood Banks periodically so that standard operating procedures are followed and such of lapses do recur in the future. A report every month should be sent to the Punjab State Blood Transfusion Council, the Chief Minister has directed.
The incident at Phagwara came to light during a joint inspection of the blood bank by drug inspectors on January 30, according to the spokesperson. A medical board was immediately constituted by Civil Surgeon Kapurthala for inquiry and for verifying the facts. During the inquiry, statements of SMO/Blood Transfusion Officer/ Lab Technician of CH Phagwara, as well as scrutiny of the record, showed that the testing of the blood was done by ELISA and Rapid test.
The blood units vide bag no. 179, collected on January 24, 2020, and unit no. 2922, collected on October 15, 2019, were found reactive during the ELISA testing technique. Following this, the LT performed a rapid test which came out to be non-reactive, thus violating the standard operating procedure where ELISA is done after Rapid Test, which is considered to the highly sensitive and mandatory for confirmation.
Even when the blood sample was found reactive as per Elisa and non-reactive by rapid test, the blood bank issued the blood to the patients, considering it to be non-reactive against all standard operating procedures.
It further came to notice during the inspection that a patient whose blood group is O+ was transfused B+ blood, which was a life-threatening lapse. The condition of the patient, a teenager, has deteriorated.
As per the rules, it was the duty of the MO who was looking after the patient and that of the SMO to report the lapse immediately to higher authorities. The SMO should have taken necessary action and should have taken steps to ensure that such a thing does not happen in the future. However, Dr. Kamal Kishore, SMO, failed in the duty to do so, necessitating his suspension.
Meanwhile, the Civil Surgeon Kapurthala has been instructed to make alternate arrangements of staff in the Phagwara Civil Hospital Blood Bank, and once the staff is in place, an inspection of the Blood Bank will be carried out by the Food & Drug Administration Department. This is expected to be completed within a week and if everything is found in order the Blood Bank will be made operational, said the spokesperson.