Meeting Transfusion Safety Expectations

The problem with success is that you've succeeded.

—Woody Allen

The public has high expectations for health care services, and this is certainly evident in its attention to virologic transmission risks in the blood supply. The focus of blood collectors, test manufacturers, and regulators on reducing the risk for transmission of HIV and hepatitis C virus (HCV) has resulted in dramatic reductions in these risks during the past 2 decades. However, linear continuation of this effort will result in inadequate attention being paid to problems that have greater impacts on transfusion recipients' morbidity and mortality and missed opportunities for substantial improvements in transfusion safety.

Since the mid-1980s, reductions in transmission risks for HIV and HCV by more than 4 orders of magnitude to less than 1 per million units have been accomplished through expanded criteria for screening donors and through improvements and expansions of blood testing technology (1). As a result of these improvements, I am comfortable offering assurance to patients, without having to append qualifying exculpations, that the blood supply is safe. When further improvements in HIV and HCV testing are available, they will undoubtedly be implemented, but actively focusing on infrequent events will yield only small health gains.

When an effective (albeit imperfect) detection system is improved, the magnitude of improvement becomes increasingly smaller with each new enhancement. For example, implementing genomic testing for HIV, with sensitive serologic testing already in place, has yielded few additional advantages and remarkably poor cost-effectiveness calculations. When a minipool format (where the samples of 16 to 24 units are pooled and tested together …