Failure of bedside ABO testing is still the most common cause of incorrect blood transfusion in the Barcode era
Introduction
ABO-incompatible red blood cell (RBC) transfusion occurs at a frequency of 1:27,000 to 1:135,207 [1], [2], [3]. About 2.11–7.06% of these cases are fatal [1], [3], [4], [5]. Consequently, the risk of dying because of a mistransfusion is higher than the risk of transmission of a viral infection during transfusion [6], [7]. The reasons for mistransfusions may be related to errors occurring in the pre-analytical, laboratory and/or clinical periods of blood transfusion. Pre-analytical errors include incorrect patient identification, donor mix-ups, and incorrect blood bag labelling. Laboratory errors may lead to incorrect blood grouping or cross-matching. Clinical errors may occur at bedside testing or when transfusing the units. Electronic data processing systems and various haemovigilance systems have been established during recent years to prevent such errors [8]. The quality control systems have led to an increased awareness of transfusion safety issues, objective standards for all procedures, improved communication between staff members, and documentation that allows retrospective case evaluation. Nevertheless, mistransfusions still occur. In this risk assessment, we will outline the causes of this problem.
Section snippets
Patients and methods
All RBC transfusions performed at the Charité University Hospital of the Humboldt University in Berlin, Germany from 1 January 1997 to 31 December 2004 were included in our analysis. The utilized quality control system, including important risk variables such as bedside ABO testing, was approved by the College of American Pathologists and did not change during the observation period. Blood samples were drawn by the physician in charge on the ward, and were immediately sent to the laboratory.
Results
A total of 343,432 RBC concentrates were transfused from 1997 to 2004. During this time, 13 ABO-incompatible units were erroneously administered to eight patients (Table 1). Several errors generally occurred in each case, resulting in a total of 21 errors (Table 2). A pre-analytical error occurred in one case, where two unconscious patients were confused and the blood samples for blood grouping and cross-matching were taken from the wrong patient. Laboratory errors occurred in four cases:
Discussion
While viral pathogens were transmitted in only one patient (HBV), erroneous ABO-incompatible RBC transfusions occurred in eight patients during the observation period. Two to three errors occurred before a patient was transfused with ABO-incompatible RBCs. Of a total of 21 errors, one (4.8%) was a pre-analytical error, 4 (19.0%) were laboratory errors, and 16 (76.2%) were clinical errors.
The investigated quality control system provided for electronic documentation of all patient data, serologic
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2009, Transfusion Medicine and HemostasisYes, we should keep ABO agglutination test within bedside transfusion checks
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