Transfusion safety from the viewpoint of a musical quintet

Dear Sir,

The former paradigm in transfusion safety was centred on the risk of infections, but this risk is now chiefly restricted to high infectious risk/high poverty areas, and/or linked to human activity, global warming and globalisation¹. While no longer the major threat, the remaining infectious risks necessitate strict vigilance programmes, a strategy that now appears to be shared with societal and political stakeholders. Within the new paradigm in transfusion safety, the cornerstone has become a secure supply, to ensure that a robust blood component inventory is built -based on patients’ needs- and that the products are distributed according to high quality standards, which comprise constant controls, traceability, surveillance and reporting. While a quintet in chamber music is an exceptionally harmonic, organised group of five instrumentalists, more prosaically it is any set or group of five persons and things. The five instruments forming the quintet of transfusion safety are as follows. 1) Patient-driven blood supply², often referred to as inventory, is the lead of the quintet, but not its soloist. 2) Infectious risk monitoring, which remains central but is now also monitored by mass media, meaning that no mistakes are admitted (the note out of time or tune is an immediate scandal, and yet when this instrument plays right, it just does what it is expected to do and draws no applause: applause and bouquets are offered to Quality Assurance, the near diva). 3) Immunology is an ornamental instrument - the most precious and sophisticated one: both the tessitura and extensiveness of its range can be appreciated. Besides issues related to immunisation and best possible matches, it produces sharps, flats and naturals, which actually tone inflammation (pro- and anti-). Immunological safety is perhaps the most sophisticated pillar and guarantees efficacy of the transfused product (both short- and long-term efficacy: the “blue note”)³. 4) Ethics is the loud-voiced instrument, always surprising because it sings differently in distinct places, as it is based on philosophy and moral principles, with cultural flavour. It should be driven -or at least directed- by society⁴. When it is out of tune, it sounds unpleasantly like echoes: in the orchestra, it is the beat. 5) A few years ago, the quintet was a quartet; the added, “you play for me” instrument, “Patient Blood Management”⁵, is a novel concept that picks up again the patients’ interests (formerly called “Transfusion Medicine”). As a new player, should PBM have to adjust to the other four instrumentalists or the other way around? Recent evidence seems to favour the latter option and ongoing studies will bring a more complete answer.

In aggregate, the beauty comes from the harmony; if transfusion safety becomes a sextet, the harmony will still prevail. As long as there are sickness and disease, music, harmony (which, in medicine and physiology, is referred to as “homeostasis”) and patients’ safety are essential; transfusion may not last forever but at the time being, it is essential and as such it must be safe along the whole supply chain, from donors to patients.