Duties and responsibilities
Provincial counsel commentary: The Krever Inquiry
Originally published January 2000 / Revised April 2008
An inquiry into the Canadian blood system recommended improved documentation and informed consent, and decreased allogeneic blood use.
Of interest to all physicians
In November 1997, Justice Horace Krever, then of the Ontario Court of Appeal, released his long-anticipated report following a three-year Commission of Inquiry into the Canadian blood system. Although by now the main players have different names, some fear the system remains alarmingly the same.
Certainly, there have been significant changes in the organizations that make up the blood system, but there are great concerns that fundamental shifts within the system have not been made to achieve greater safety for patients. Blood utilization techniques vary widely across the country. Record-keeping in many hospitals remains antiquated and inadequate to address vein-to-vein tracing of product. It is likely that the recording of informed consent and the taking of adequate transfusion histories vary greatly from physician to physician despite Justice Krever's recommendation that provincial licensing bodies require such informed consent in their standards of practice. It therefore remains relevant for you to reflect on how you and your hospital/practice are complying with Justice Krever's recommendations.
For most physicians, the impact of the Inquiry reaches back to an interim report that was released in 1995 and dealt with four main issues:
- The first response by Justice Krever to the tainted blood episode was to recommend the reduction of product use. Directors of hospital blood banks were asked to develop procedures to review and audit proposed and actual blood use by physicians. Alternatives to allogeneic blood transfusion were recommended, including organizing autologous blood programs. Indeed, hospitals were asked to ensure physicians informed patients of the availability of autologous blood donation whenever they were to undergo elective surgery. This included providing written information about autologous donation.
- The interim report also addressed the need for physicians to provide patients with information about the risks, benefits and alternatives of allogeneic blood use. Informed consent was to be given in language that patients could clearly understand and time was to be left to allow for questions and for patient assimilation of the information. The discussion was to be clearly recorded in the patient chart.
- Physicians were also directed to take a blood transfusion history from patients and to routinely ask any HIV or HCV patients about the dates and locations of any blood donations. If the physician had any concern about a suspect donation that might create risk to blood recipients, the physician was to secure the patient's consent to report the donation to the authorities.
- Finally, the fact of a transfusion was to be well documented, including reference on the patient's chart pertaining to the blood and blood components administered during a hospital stay. Information about blood administration was to be recorded in the discharge summary and included in the reporting letter written by the attending physician to the referring physician.
These recommendations all had to do with the ability of the system to trace back where and when potential victims may have been exposed to tainted blood products. This requirement was adopted into the final report. Justice Krever recommended that such capability be a condition of supplying blood and blood products to a hospital, that the hospital maintain adequate records and that the national blood service's standards for storing product be observed.