Flawed Blood-Tracking System Puts Soldiers at Risk

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Soldiers could be at risk of getting transfusions of infected blood because of flaws and mismanagement of the military's automated blood-tracking system, Pentagon investigators warned.

Defense Department health officials acknowledged the problems and said they hope to have the most serious ones fixed by 2003. Last month, IBM took over part of the program's troubleshooting functions from a Defense Department office.

The Defense Blood Standard System is the military's program to keep track of blood and its derivatives from donation through transfusion. Running the system cost $70.1 million from 1991 to 2000, and projected operating costs for the next six years are $43.8 million.

A report released Oct. 22 by the Defense Department's inspector general found that the system couldn't do several things it was supposed to when it was planned in 1991.

• The program cannot keep track of all blood donors who were banned from a military donation center, meaning a banned donor could be allowed to give blood elsewhere.

• It cannot fully track everyone who receives blood products from a tainted donation.

• It cannot link with the equipment that screens blood for germs. That means workers must manually enter test results for each unit of blood, increasing the chance of mistakes.

Those and other lapses could "increase the risk of blood inventory errors and possibly result in the inappropriate release of blood products," the report said. The chance for errors is greatest during wartime, when the system is strained by the extra need for blood, the report said.

Of the five military organizations that commented on the report, only the Air Force disagreed with that finding. Other safeguards outside the tracking system help prevent such errors, Air Force Maj. Gen. James G. Roudebush wrote in response to the audit.

"Use of DBSS has reduced errors in inappropriate release of blood products," wrote Roudebush, a deputy surgeon general.

The Pentagon plans to fix the donor and recipient tracking problems, as well as create a link to the testing equipment, starting next year.

The report said other problems with the system include:

• Lack of replacements for portable computers used to record information during blood drives. One military blood collection group was without this equipment for six months. The lack of computer equipment meant information about the blood had to be entered manually.

Defense Department health officials disagreed with the investigators' suggestion that they buy more of the mobile equipment to use as backups. Instead, "a root cause analysis" is being done to determine the best way to fix the problem, wrote Dr. J. Jarrett Clinton, the acting assistant defense secretary for health affairs.

• Poor response to user complaints. Last May, the system included 131 temporary fixes to problems that allowed users to work around trouble spots. A change made that helped blood donor centers created more work for blood processing centers.

"The blood processing laboratories indicated that although they could accommodate the extra work required during peacetime, in the event of a wartime situation ... they would not be able to adequately meet their mission," the report said.

The hiring of IBM to help respond to user complaints will help solve such problems, Clinton wrote.

• Inadequate training and testing of system users. The computerized training course for the blood tracking system doesn't include information on several system upgrades, for example. Offices that use the program also did not create standard competency tests for system administrators, as required by the Food and Drug Administration, the report said.

The training program will be updated with each new version of DBSS, starting with a version due out next August, Clinton wrote. System administrators are now being tested every three months, he wrote.