Refrigeration Failures - Bringing the Problem in from the Cold

Abstract

Aim Review of four failures of refrigeration facilities in Victorian institutional blood banks reported to ARCBS in the first 4 months of 2004. These incidents at both public and private institutions, in metropolitan and regional settings, resulted in loss of 148 units of red cells, 7 vials of RhD Ig and 2 bottles of Albumex. Incidents were investigated and root causes identified by initial phone interview and visits to blood bank storage facilities. Result Case 1: Temperature fell below 0 °C at remote site, alarm was activated at monitoring centre (main lab) but without response. Case 2: Power failure resulted in rise in temperature. Alarm did not activate until power was restored. Alarms were set outside required storage temperatures. Case 3: Circuit failure resulted in loss of power. Alarm was activated, but then switched off and no further action taken. Case 4: Compressor failure resulted in alarm activation. Alarm and monitoring devices were deactivated while repairs carried out. Product was not moved to other storage facilities. These cases all highlight the importance of procedures, training, equipment and maintenance. Conclusion Losses of precious blood components and products through refrigeration failures are preventable. Vital improvements should include commissioning refrigeration equipment that meets AS 3864, protocol development and staff training in use of procedures to be followed when out of temperature events occur, and performance of regular preventative maintenance, calibration and testing of storage and monitoring equipment. ARCBS can work with institutional blood banks to improve storage and management of blood.