concentrated. Perhaps the government's Medicine Control Agency could or should extend its role from safety to include efficacy, cost-benefit, and appropriate limited availability. Such an agency would work to establish clear evidence of benefits in relation to cost and provide a more informed basis for rationing decisions. It might be vulnerable to political pressure but it is less likely to allow the local variations in availability of very expensive drugs that now exist. In particular, it could ensure that funding decisions properly reflect where the drugs should be used-in hospital, primary care, or shared care. If this centralised approach is not followed then a similar approach should be adopted by regional health authorities, which control allocation of funds to both the family health services authorities and hospital and community health services. The region not only has greater purchasing power but its budget base is so much larger and more amenable to accommodating expensive items. An example from one region is that only 10% of growth hormone is purchased by hospitals while the remainder is purchased by retail chemists from four different suppliers. This does not represent effective purchasing within a total budget in excess of £4m a year. The current approach of leaving hard decisions to local providers has not been in the best interests of patients because too often it has resulted in unpleasant squabbles between health professionals and allegations of "buck passing." It has also led to media publicity being applied to individual cases, which have been judged irrationally and without reference to other cases of need. We suggest that the government and regional health authorities urgently consider these issues and provide guidance to the local prescribing working groups. Pivotal to any discussions at a local level is for the method of funding to accompany the pattern of prescribing devised jointly by hospital and general practitioners. This requires government and regional approval and financial support. Only in this way may there be hope for the rational use of expensive drugs until a national mechanism is established. P G KOPELMAN C W BARRETT Newham General Hospital, London E13 8RU 1 Gabriel R. Picking up the tab for erythropoietin. BMJ 1991;302: 248-9,864. (2 February; correction 13 April.)
Postnatal depression and infant development SIR,-I hope that every general practitioner reads, marks, and inwardly digests the review ofpostnatal depression and infant development by Dr Lynne Murray and colleagues.' I entirely concur with their conclusions but would like to sound a word of caution about the use of a screening questionnaire in the early puerperium. I have found that several patients who I have identified with the Edinburgh postnatal depression scale have not wished to be labelled "a patient with depression" while others have asked me not to inform our excellent health visitors of their high scores. As some women with postnatal depression may not wish to inform their general practitioners or health visitors that they are depressed2 the primary care team should be "patient friendly" and apply the tool with sensitivity. Grant, in a small study in my practice, found that 65% (15/23) of a sample of depressed (11) and non-depressed (12) mothers feared that disclosure of depressive symptoms would meet with an unsympathetic response; 48% (11/23) felt that depression in the puerperium carried a serious stigma, and 39% (9/23) believed that depression implied "failure as a mother" (unpublished data).
1336
She found that 74% (17/23) would have appreciated more discussion about the possibilities of postnatal depression in their antenatal care and 78% (18/23) would have liked more information about postnatal depression in the puerperium. Patients with postnatal depression should not have any stigma attached to them either by society or by general practitioners.2 Information about the condition should be more readily available, particularly in the antenatal period, so that more women are prepared to acknowledge it and seek help should they experience it. JONATHAN P RICHARDS Dowlais Health Centre, Merthyr Tydfil CF48 3AB
The functional effectiveness of achieving grade II mobility could have been nicely illustrated by using an activities of daily living assessment-for example, the Barthel, measuring it with and without the prosthesis. Similarly, a patient's ability to transfer with an expensive modular system could be compared with that with a simpler low specification prosthesis, providing an opportunity for savings without compromising on functional results. CHRISTINE COLLIN Department of Clinical Geratology, Radcliffe Infirmary, Oxford OX2 6HE I Hanspal RS, Fisher K. Assessment ofcognitive and psychomotor
1 Murray L, Cooper PJ, Stein A. Postnatal depression and infant development. BMJ 1991;302:978-9. (27 April.) 2 Richards JP. Postnatal depression: a review of recent literature. BrJ Gen Pract 1990;40:472-6.
SIR,-The review by Dr Lynne Murray and colleagues maintains the possibility that an adverse relation exists between postpartum depression and the cognitive development of the offspring and stresses the importance in diagnosing and treating depression in the postnatal period. ' To date there have been no epidemiologic studies to evaluate whether infant development may be affected by the presence of maternal depression or by the secondary exposure of the infant to psychotherapeutic agents ingested by the mother for the treatment of postpartum depression and excreted in breast milk. It is hoped that, as larger populations are studied to evaluate the association between postpartum depression and its effects on infant development, efforts will be made to answer the longstanding question as to what part, if any, chronic secondary exposure of the infant to psychotherapeutic agents may play. BRIAN F SHEA Division of Research, Education, and Drug Information, Brigham and Women's Hospital, Boston, Massachusetts 02115, United States 1 Murray L, Cooper PJ, Stein A. Postnatal depression and infant development. BMJ 1991;302:978-9. (27 April.)
function and rehabilitation of elderly people with prostheses. BMJ7 1991;302:940. (20 April.)
AUTHORS' REPLY,-Our study did not aim to describe the functional results and outcome of prosthetic rehabilitation of elderly amputees, but to show the significance of the relation between cognitive and psychomotor function and mobility. We recognise that achieving grade II mobility is also a valuable rehabilitation goal, especially for below knee amputees. In our paper grade III mobility was just an illustration in case some readers believed that we were suggesting that low cognitive assessment scores automatically precluded limb fitting. Although the use of the state of the art modular limbs to achieve grade II mobility may be questioned, it is worth noting that the simpler low specification prostheses is more labour intensive and hence more expensive (about 15% for below knee amputees and 20% for above knee amputees). Because the aim of the study was not to address functional effectiveness of any grade the use of Bartel indices for assessing activities of daily living was not relevant. The point was to investigate the predictive value of cognitive state for achievable mobility. Having established the relationship, we are now undertaking a prospective study on the value of the use of cognitive assessment scales in rehabilitation after amputation. R S HANSPAL KEREN FISHER
Disablement Services Department, Royal National Orthopaedic Hospital, Stanimore, Middlesex HA7 4LP
Rehabilitation of elderly people with prostheses
Preventing needlestick injuries
SIR,-Mr R S Hanspal and Ms Keren Fisher's interesting study of outcome in unilateral amputees' warrants further comment. The results of prosthetic rehabilitation at first seem too good to be true, with only 3% of patients having abandoned the prosthesis while 66% were walking both indoors and outdoors. I suspect the explanation lies in the recruitment of patients from those reattending the clinic rather than from all patients provided with a prosthesis. This suggestion is supported by the sex ratio of more than two women to one man, being the reverse of that normally encountered among vascular amputees. There is no evidence that these results can be extrapolated to an unselected prospective group of unilateral amputees. The authors correctly point out that achieving grade III mobility (indoor walking only) is a worthwhile rehabilitation aim, but achieving grade II mobility (use of a prosthesis to achieve a transfer) is also a valuable rehabilitation aim. Being able to transfer independently can have a significant effect on reducing the cost of care to the community and with this skill patients can safely look after themselves throughout the day. What is questionable is whether a state of the art, expensive modular limb is the appropriate prosthesis if grade II mobility is the rehabilitation goal.
SIR,-To prevent needlestick injuries the principles should be (a) to minimise the duration of time for which the needle is exposed; (b) to avoid as far as possible manoeuvres that bring the hand close to the needlepoint; and (c) to discourage complicated manoeuvres while the needle point is exposed. The more complicated the manoeuvres, and the longer the period that the needle point is exposed, the more likely is the risk of a needlestick injury to the operator and to third parties. Dr D C Anderson and colleagues proposed that resheathing needles would prevent injuries to a third party and illustrated three methods for doing this.' We doubt the safety of the manual techniques illustrated. The gravity resheathing method has the potential for causing a self inflicted injury, especially if the operator were tired, distracted, or bumped intoall of which can occur to staff, particularly in busy departments. It would be more appropriate in busy areas to dispose of the needle as soon as possible after use into a safe and secure container and to avoid any prolonged manipulation of the needle. If a two handed technique is used in the scoop resheathing method (one hand steadying the sheath while the other advances the needle into the sheath) there is a risk of stabbing the hand holding the sheath. If a one handed technique is used,
BMJ
VOLUME 302
1 JUNE 1991
trying to push a used needle into a movable sheath and then turning the syringe upwards to let the sheath cover the needle could lead to "chasing" the sheath across the surface of the table, flipping the sheath off on to the floor, and injuring a bystander in the process. The Saf-T-Cap and other similar devices would still require a steady hand and eye to put the needle into the sheath at the first attempt. There might also be the temptation to steady the device with the other hand while using it, thereby increasing the risk of a needlestick injury to that hand. We accept that if there are situations where recapping is unavoidable, the Saf-T-Cap is simple enough and better in many aspects than some of the more complicated alternative multiple hole devicessome with cutter attachments to remove the needle from the syringe. The advice of the Centers for Disease Control and the British Medical Association,2 that resheathing is generally inadvisable, is still sound. We would also support the requirement for all sharps containers to meet British Safety standards (7320). Rather than recommending resheathing we recommend the adequate provision, use, and disposal of robust sharps containers at suitable intervals and a programme to educate all staff in the safe disposal of sharps, as required by the Control of Substances Hazardous to Health Regulations 1988. T C AW
Institute of Occupational Health, University of Birmingham, Birmingham A E COCKCROFT
Occupational Health Unit, Hampstead Health Authority, London P J BAXTER Department of Community Medicine, University of Cambridge, Cambridge
J R CARRUTHERS Occupational Health Service,
King's College Hospital, London N A MITCHELL-HEGGS
Department of Occupational Health, St George's Hospital, London H A WALDRON
Department of Occupational Health, St Mary's Hospital, London
1 Anderson DC, Blower AL, Packer JMV, Ganguli LA. Preventing needlestick injuries. BMJ 1991;302:769-70. (30 March.) 2 British Medical Association. A code ofpractice for the safe use and disposal ofsharps. London: BMA, 1990.
It is, however, the responsibility of the infection control team to keep on at our clinical colleagues to rouse themselves from the habits of a lifetime and at managers to make these resources readily available so all may comply with our guidelines. It is only then that we will be taken seriously and not chastised for handing out counsels of perfection from ivory towers. Finally, we believe that those involved in infection control have a great deal to offer in upholding and re-emphasising the need for safe and efficient practices in our hospitals and in the community, especially in the face of continued pressures to cut corners, skimp, and save. We must, however, be seen to be effective and authoritative in these areas if our clinical colleagues are to be convinced that some of their hard won clinical budgets should be spent in maintaining our services in the future. SARAH MAXWELL MARGARET VEGUILLAS Pathology Department, Stepping Hill Hospital, Stockport SK2 7JE 1 Anderson DC, Blower AL, Packer LA, Ganguli LA. Preventing needlestick injuries. BMJ 1991;302:769-70. (30 March.) 2 Valentine C, Bright P. Preventing needlestick injuries. BMJ 1991;302:1079. (4 May.)
Living without tears SIR,-I was interested to read the article "Living without tears" by Ms Joanna Johnson. There now exists a mutual self help organisation called the British Sjogren's Syndrome Association (BSSA, 7 Winchdells, Bennetts End, Hemel Hempstead, Hertfordshire HP3 8HZ), which welcomes also those with non-Sjogren dry eye or dry mouth problems to become members and join its activities. The association aims to support sufferers from Sjogren's syndrome and related disorders and also patients with other dry eye problems; increase awareness of these disorders in the medical and dental professions and among the general public; and promote and support research in these complex ailments. Several branches of the association have recently been formed, mainly in the bigger centres such as Manchester and Glasgow. The first national conference of the British Sjogren's Syndrome Association will be held on 19 July 1991 at the University of Birmingham Conference Centre. B PAL
University Hospital of South Manchester,
SIR,-We would like to add a few observations to the debate over whether or not to sheath.' 2 Over the past six months there have been 69 incidents in our district in which the transmission of bloodborne viruses has been a possibility42 involved actual handling during a procedure; 13, improper disposal; two, patients' own sharps; 11, a scratch or bite; and one a splash in the eye. These show that, although efforts to ensure the safe disposal of sharps must still be maintained, greater attention should probably be given to the major risk area of the actual procedural handling of sharps and needles. As large volumes of blood are potentially available at this point these incidents pose by far the greatest danger to health care workers, as indeed indicated by Dr D C Anderson and colleagues. ' We agree that "faced with a sharps box [conforming to BS 7320], a needle and sheath"2 the sensible, safe, and correct action is to dispose of the unsheathed needle straight into the box. In the real world, however, such an ideal situation rarely exists. We are currently trying to make available small, user friendly sharps boxes at every point of use. Yet we foresee that equipment availability, financial constraints, management inactivity, and user apathy are all too likely to conspire against this eminently achievable state of bliss.
BMJ VOLUME 302
1 JUNE 1991
Manchester M20 8LR 1 Johnson J. Living without tears. BMJ 1991;302:1158-9.
(11 May.)
Identification of patients when taking blood SIR,-The BMJ has published an excellent series of articles in the "ABC of Transfusion," which later has appeared as a book edited by Dr Marcela Contreras.' In the chapter on testing before transfusion, and blood ordering policies, however, the authors state, "The person taking the blood sample must ensure that the patient is properly identified, either by speaking to the patient or-if the patient is unconscious-by examining the wrist band. Ideally, the tubes should be labelled after they have been filled with blood." The procedure described in the last sentence seems very dangerous to us. The following example illustrates why. A cord blood sample was drawn from a newborn in the delivery room, but unfortunately the tube was left unlabelled-and forgotten and not sent to the blood bank. The delivery room was cleared and cleaned for the next patient, but the unlabelled sample was not removed. During the subsequent
delivery someone labelled the tube with identification characteristics for that delivery. The results of blood grouping on this sample did not fit mendelian rules of inheritance of the ABO groups between the recorded mother and child. The error was finally resolved, indicating to us once more that proper labelling of test tubes before drawing any blood is an important step in the sequence to ensure that blood in the tube matches patient identification on the label. One might think that the person who takes the blood sample should take the time to label the tubes properly after drawing the blood and before engaging in other work. In the stressed work situations in today's hospital setting this will often be impossible. Doctors and nurses often must leave their work in a hurry to deal with acute situations. In Denmark the only approved sequence of steps when taking blood for grouping or compatibility testing was described by E Freiesleben.2 The following steps are mandatory: the requisition is filled in and the test tubes labelled with the patient's full name and civil register number (this social security number unequivocally identifies the person and is a blessing for safe blood banking and computerisation). Then the venepuncture is done, and while the blood is streaming into the tube the patient is asked to state his or her name and his number (or date of birth, which comprises the first six figures in the number), and the person drawing blood checks that this information accords with the label on the tube. For unconscious patients and children, an assistant reads the full name and number from the patient's wrist band, and the labelling of the tube is controlled by the person drawing blood. If health care workers drawing blood samples always adhere to these rules the mistakes due to mixed up specimens can be greatly diminished. J0RGEN GEORGSEN UFFE BRODTHAGEN NIELS GRUNNET SVEND ERIK HOVE JACOBSEN CASPER JERSILD Regional Centre for Blood Transfusion and Clinical Immunology, Aalborg Hospital, DK-9100 Aalborg, Denmark 1 Contreras M, Mollison PL. Testing before transfusion, and blood ordering policies. In: Contreras M, ed. ABC of transfusion. London: BMJ, 1990:6. 2 Freiesleben E. Vejiledning i blodtransfusion [Recommendations for blood transfusion]. Vol 1. Copenhagen: Blood Transfusion Board, 1965:18-9.
AUTHOR'S REPLY, - Haemolytic transfusion reactions and deaths resulting from transfusions are still due mainly to identification mistakes. One of the most important causes of such mistakes is the failure to label sample tubes correctly. The main problem is one of non-compliance with standard operating procedures or hospital guidelines. ' Dr Georgsen and colleagues have given us an example of failure of compliance when a tube was not labelled after the blood had been drawn. The health care worker concerned was negligent by leaving a sample unlabelled in theatre. Fortunately, apart from a great deal of aggravation, the infants concerned seemed to have come to no harm. On the other hand, I have also had to deal with investigations of transfusion fatalities because phlebotomists labelled tubes for two or three patients before drawing the blood. The consequence was that samples went into the tubes labelled for the wrong patient, with fatal consequences (group 0 recipient labelled as A and given group A blood). Professor Mollison and I were prompted to advise on labelling the tubes after they have been filled with blood because of our personal experiences.
1337
Postnatal depression and infant development SIR,-I hope that every general practitioner reads, marks, and inwardly digests the review ofpostnatal depression and infant development by Dr Lynne Murray and colleagues.' I entirely concur with their conclusions but would like to sound a word of caution about the use of a screening questionnaire in the early puerperium. I have found that several patients who I have identified with the Edinburgh postnatal depression scale have not wished to be labelled "a patient with depression" while others have asked me not to inform our excellent health visitors of their high scores. As some women with postnatal depression may not wish to inform their general practitioners or health visitors that they are depressed2 the primary care team should be "patient friendly" and apply the tool with sensitivity. Grant, in a small study in my practice, found that 65% (15/23) of a sample of depressed (11) and non-depressed (12) mothers feared that disclosure of depressive symptoms would meet with an unsympathetic response; 48% (11/23) felt that depression in the puerperium carried a serious stigma, and 39% (9/23) believed that depression implied "failure as a mother" (unpublished data).
1336
She found that 74% (17/23) would have appreciated more discussion about the possibilities of postnatal depression in their antenatal care and 78% (18/23) would have liked more information about postnatal depression in the puerperium. Patients with postnatal depression should not have any stigma attached to them either by society or by general practitioners.2 Information about the condition should be more readily available, particularly in the antenatal period, so that more women are prepared to acknowledge it and seek help should they experience it. JONATHAN P RICHARDS Dowlais Health Centre, Merthyr Tydfil CF48 3AB
The functional effectiveness of achieving grade II mobility could have been nicely illustrated by using an activities of daily living assessment-for example, the Barthel, measuring it with and without the prosthesis. Similarly, a patient's ability to transfer with an expensive modular system could be compared with that with a simpler low specification prosthesis, providing an opportunity for savings without compromising on functional results. CHRISTINE COLLIN Department of Clinical Geratology, Radcliffe Infirmary, Oxford OX2 6HE I Hanspal RS, Fisher K. Assessment ofcognitive and psychomotor
1 Murray L, Cooper PJ, Stein A. Postnatal depression and infant development. BMJ 1991;302:978-9. (27 April.) 2 Richards JP. Postnatal depression: a review of recent literature. BrJ Gen Pract 1990;40:472-6.
SIR,-The review by Dr Lynne Murray and colleagues maintains the possibility that an adverse relation exists between postpartum depression and the cognitive development of the offspring and stresses the importance in diagnosing and treating depression in the postnatal period. ' To date there have been no epidemiologic studies to evaluate whether infant development may be affected by the presence of maternal depression or by the secondary exposure of the infant to psychotherapeutic agents ingested by the mother for the treatment of postpartum depression and excreted in breast milk. It is hoped that, as larger populations are studied to evaluate the association between postpartum depression and its effects on infant development, efforts will be made to answer the longstanding question as to what part, if any, chronic secondary exposure of the infant to psychotherapeutic agents may play. BRIAN F SHEA Division of Research, Education, and Drug Information, Brigham and Women's Hospital, Boston, Massachusetts 02115, United States 1 Murray L, Cooper PJ, Stein A. Postnatal depression and infant development. BMJ 1991;302:978-9. (27 April.)
function and rehabilitation of elderly people with prostheses. BMJ7 1991;302:940. (20 April.)
AUTHORS' REPLY,-Our study did not aim to describe the functional results and outcome of prosthetic rehabilitation of elderly amputees, but to show the significance of the relation between cognitive and psychomotor function and mobility. We recognise that achieving grade II mobility is also a valuable rehabilitation goal, especially for below knee amputees. In our paper grade III mobility was just an illustration in case some readers believed that we were suggesting that low cognitive assessment scores automatically precluded limb fitting. Although the use of the state of the art modular limbs to achieve grade II mobility may be questioned, it is worth noting that the simpler low specification prostheses is more labour intensive and hence more expensive (about 15% for below knee amputees and 20% for above knee amputees). Because the aim of the study was not to address functional effectiveness of any grade the use of Bartel indices for assessing activities of daily living was not relevant. The point was to investigate the predictive value of cognitive state for achievable mobility. Having established the relationship, we are now undertaking a prospective study on the value of the use of cognitive assessment scales in rehabilitation after amputation. R S HANSPAL KEREN FISHER
Disablement Services Department, Royal National Orthopaedic Hospital, Stanimore, Middlesex HA7 4LP
Rehabilitation of elderly people with prostheses
Preventing needlestick injuries
SIR,-Mr R S Hanspal and Ms Keren Fisher's interesting study of outcome in unilateral amputees' warrants further comment. The results of prosthetic rehabilitation at first seem too good to be true, with only 3% of patients having abandoned the prosthesis while 66% were walking both indoors and outdoors. I suspect the explanation lies in the recruitment of patients from those reattending the clinic rather than from all patients provided with a prosthesis. This suggestion is supported by the sex ratio of more than two women to one man, being the reverse of that normally encountered among vascular amputees. There is no evidence that these results can be extrapolated to an unselected prospective group of unilateral amputees. The authors correctly point out that achieving grade III mobility (indoor walking only) is a worthwhile rehabilitation aim, but achieving grade II mobility (use of a prosthesis to achieve a transfer) is also a valuable rehabilitation aim. Being able to transfer independently can have a significant effect on reducing the cost of care to the community and with this skill patients can safely look after themselves throughout the day. What is questionable is whether a state of the art, expensive modular limb is the appropriate prosthesis if grade II mobility is the rehabilitation goal.
SIR,-To prevent needlestick injuries the principles should be (a) to minimise the duration of time for which the needle is exposed; (b) to avoid as far as possible manoeuvres that bring the hand close to the needlepoint; and (c) to discourage complicated manoeuvres while the needle point is exposed. The more complicated the manoeuvres, and the longer the period that the needle point is exposed, the more likely is the risk of a needlestick injury to the operator and to third parties. Dr D C Anderson and colleagues proposed that resheathing needles would prevent injuries to a third party and illustrated three methods for doing this.' We doubt the safety of the manual techniques illustrated. The gravity resheathing method has the potential for causing a self inflicted injury, especially if the operator were tired, distracted, or bumped intoall of which can occur to staff, particularly in busy departments. It would be more appropriate in busy areas to dispose of the needle as soon as possible after use into a safe and secure container and to avoid any prolonged manipulation of the needle. If a two handed technique is used in the scoop resheathing method (one hand steadying the sheath while the other advances the needle into the sheath) there is a risk of stabbing the hand holding the sheath. If a one handed technique is used,
BMJ
VOLUME 302
1 JUNE 1991
trying to push a used needle into a movable sheath and then turning the syringe upwards to let the sheath cover the needle could lead to "chasing" the sheath across the surface of the table, flipping the sheath off on to the floor, and injuring a bystander in the process. The Saf-T-Cap and other similar devices would still require a steady hand and eye to put the needle into the sheath at the first attempt. There might also be the temptation to steady the device with the other hand while using it, thereby increasing the risk of a needlestick injury to that hand. We accept that if there are situations where recapping is unavoidable, the Saf-T-Cap is simple enough and better in many aspects than some of the more complicated alternative multiple hole devicessome with cutter attachments to remove the needle from the syringe. The advice of the Centers for Disease Control and the British Medical Association,2 that resheathing is generally inadvisable, is still sound. We would also support the requirement for all sharps containers to meet British Safety standards (7320). Rather than recommending resheathing we recommend the adequate provision, use, and disposal of robust sharps containers at suitable intervals and a programme to educate all staff in the safe disposal of sharps, as required by the Control of Substances Hazardous to Health Regulations 1988. T C AW
Institute of Occupational Health, University of Birmingham, Birmingham A E COCKCROFT
Occupational Health Unit, Hampstead Health Authority, London P J BAXTER Department of Community Medicine, University of Cambridge, Cambridge
J R CARRUTHERS Occupational Health Service,
King's College Hospital, London N A MITCHELL-HEGGS
Department of Occupational Health, St George's Hospital, London H A WALDRON
Department of Occupational Health, St Mary's Hospital, London
1 Anderson DC, Blower AL, Packer JMV, Ganguli LA. Preventing needlestick injuries. BMJ 1991;302:769-70. (30 March.) 2 British Medical Association. A code ofpractice for the safe use and disposal ofsharps. London: BMA, 1990.
It is, however, the responsibility of the infection control team to keep on at our clinical colleagues to rouse themselves from the habits of a lifetime and at managers to make these resources readily available so all may comply with our guidelines. It is only then that we will be taken seriously and not chastised for handing out counsels of perfection from ivory towers. Finally, we believe that those involved in infection control have a great deal to offer in upholding and re-emphasising the need for safe and efficient practices in our hospitals and in the community, especially in the face of continued pressures to cut corners, skimp, and save. We must, however, be seen to be effective and authoritative in these areas if our clinical colleagues are to be convinced that some of their hard won clinical budgets should be spent in maintaining our services in the future. SARAH MAXWELL MARGARET VEGUILLAS Pathology Department, Stepping Hill Hospital, Stockport SK2 7JE 1 Anderson DC, Blower AL, Packer LA, Ganguli LA. Preventing needlestick injuries. BMJ 1991;302:769-70. (30 March.) 2 Valentine C, Bright P. Preventing needlestick injuries. BMJ 1991;302:1079. (4 May.)
Living without tears SIR,-I was interested to read the article "Living without tears" by Ms Joanna Johnson. There now exists a mutual self help organisation called the British Sjogren's Syndrome Association (BSSA, 7 Winchdells, Bennetts End, Hemel Hempstead, Hertfordshire HP3 8HZ), which welcomes also those with non-Sjogren dry eye or dry mouth problems to become members and join its activities. The association aims to support sufferers from Sjogren's syndrome and related disorders and also patients with other dry eye problems; increase awareness of these disorders in the medical and dental professions and among the general public; and promote and support research in these complex ailments. Several branches of the association have recently been formed, mainly in the bigger centres such as Manchester and Glasgow. The first national conference of the British Sjogren's Syndrome Association will be held on 19 July 1991 at the University of Birmingham Conference Centre. B PAL
University Hospital of South Manchester,
SIR,-We would like to add a few observations to the debate over whether or not to sheath.' 2 Over the past six months there have been 69 incidents in our district in which the transmission of bloodborne viruses has been a possibility42 involved actual handling during a procedure; 13, improper disposal; two, patients' own sharps; 11, a scratch or bite; and one a splash in the eye. These show that, although efforts to ensure the safe disposal of sharps must still be maintained, greater attention should probably be given to the major risk area of the actual procedural handling of sharps and needles. As large volumes of blood are potentially available at this point these incidents pose by far the greatest danger to health care workers, as indeed indicated by Dr D C Anderson and colleagues. ' We agree that "faced with a sharps box [conforming to BS 7320], a needle and sheath"2 the sensible, safe, and correct action is to dispose of the unsheathed needle straight into the box. In the real world, however, such an ideal situation rarely exists. We are currently trying to make available small, user friendly sharps boxes at every point of use. Yet we foresee that equipment availability, financial constraints, management inactivity, and user apathy are all too likely to conspire against this eminently achievable state of bliss.
BMJ VOLUME 302
1 JUNE 1991
Manchester M20 8LR 1 Johnson J. Living without tears. BMJ 1991;302:1158-9.
(11 May.)
Identification of patients when taking blood SIR,-The BMJ has published an excellent series of articles in the "ABC of Transfusion," which later has appeared as a book edited by Dr Marcela Contreras.' In the chapter on testing before transfusion, and blood ordering policies, however, the authors state, "The person taking the blood sample must ensure that the patient is properly identified, either by speaking to the patient or-if the patient is unconscious-by examining the wrist band. Ideally, the tubes should be labelled after they have been filled with blood." The procedure described in the last sentence seems very dangerous to us. The following example illustrates why. A cord blood sample was drawn from a newborn in the delivery room, but unfortunately the tube was left unlabelled-and forgotten and not sent to the blood bank. The delivery room was cleared and cleaned for the next patient, but the unlabelled sample was not removed. During the subsequent
delivery someone labelled the tube with identification characteristics for that delivery. The results of blood grouping on this sample did not fit mendelian rules of inheritance of the ABO groups between the recorded mother and child. The error was finally resolved, indicating to us once more that proper labelling of test tubes before drawing any blood is an important step in the sequence to ensure that blood in the tube matches patient identification on the label. One might think that the person who takes the blood sample should take the time to label the tubes properly after drawing the blood and before engaging in other work. In the stressed work situations in today's hospital setting this will often be impossible. Doctors and nurses often must leave their work in a hurry to deal with acute situations. In Denmark the only approved sequence of steps when taking blood for grouping or compatibility testing was described by E Freiesleben.2 The following steps are mandatory: the requisition is filled in and the test tubes labelled with the patient's full name and civil register number (this social security number unequivocally identifies the person and is a blessing for safe blood banking and computerisation). Then the venepuncture is done, and while the blood is streaming into the tube the patient is asked to state his or her name and his number (or date of birth, which comprises the first six figures in the number), and the person drawing blood checks that this information accords with the label on the tube. For unconscious patients and children, an assistant reads the full name and number from the patient's wrist band, and the labelling of the tube is controlled by the person drawing blood. If health care workers drawing blood samples always adhere to these rules the mistakes due to mixed up specimens can be greatly diminished. J0RGEN GEORGSEN UFFE BRODTHAGEN NIELS GRUNNET SVEND ERIK HOVE JACOBSEN CASPER JERSILD Regional Centre for Blood Transfusion and Clinical Immunology, Aalborg Hospital, DK-9100 Aalborg, Denmark 1 Contreras M, Mollison PL. Testing before transfusion, and blood ordering policies. In: Contreras M, ed. ABC of transfusion. London: BMJ, 1990:6. 2 Freiesleben E. Vejiledning i blodtransfusion [Recommendations for blood transfusion]. Vol 1. Copenhagen: Blood Transfusion Board, 1965:18-9.
AUTHOR'S REPLY, - Haemolytic transfusion reactions and deaths resulting from transfusions are still due mainly to identification mistakes. One of the most important causes of such mistakes is the failure to label sample tubes correctly. The main problem is one of non-compliance with standard operating procedures or hospital guidelines. ' Dr Georgsen and colleagues have given us an example of failure of compliance when a tube was not labelled after the blood had been drawn. The health care worker concerned was negligent by leaving a sample unlabelled in theatre. Fortunately, apart from a great deal of aggravation, the infants concerned seemed to have come to no harm. On the other hand, I have also had to deal with investigations of transfusion fatalities because phlebotomists labelled tubes for two or three patients before drawing the blood. The consequence was that samples went into the tubes labelled for the wrong patient, with fatal consequences (group 0 recipient labelled as A and given group A blood). Professor Mollison and I were prompted to advise on labelling the tubes after they have been filled with blood because of our personal experiences.
1337
