Failure of bedside ABO testing is still the most common cause of incorrect blood transfusion in the Barcode era

https://doi.org/10.1016/j.transci.2005.04.006Get rights and content

Abstract

Background and objectives. ABO-incompatible red blood cell (RBC) transfusions are a major risk in transfusion medicine. Identification of factors leading to this hazard is important to improve transfusion safety.

Material and methods. All consecutive erroneous ABO-incompatible transfusions occurring from January 1997 to December 2004 at the Charité University Hospital in Berlin, Germany were analysed.

Results. A total of 343,432 RBC units were transfused, and eight patients erroneously received 13 ABO-incompatible RBC concentrates. The most frequent error was incorrect bedside testing (n = 7). Intensive care treatment was required in two cases, but there were no fatal mistransfusions. Four patients had no or only mild reactions.

Conclusion. Mistransfusions are still a considerable risk in transfusion medicine despite quality control systems and electronic data processing. An increase in transfusion safety may require the introduction of further systems, e.g. radio-frequency identification (RFID) tags.

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

References (23)

  • J. Chiaroni et al.

    Analysis of ABO discrepancies occurring in 35 French hospitals

    Transfusion

    (2004)
  • Cited by (30)

    • Blood Still Kills: Six Strategies to Further Reduce Allogeneic Blood Transfusion-Related Mortality

      2010, Transfusion Medicine Reviews
      Citation Excerpt :

      Moreover, because proper identification of the transfusion recipient is crucial, barrier systems intended to physically prevent the transfusion of blood without correct identification of the patient have been devised. These include a plastic lock that must be unlocked by the entry of the correct identification code,162 use of a special wristband for identification of transfusion recipients,163,164 multiple barcodes (on patient wristbands, blood sample tubes, blood component bags, and nurses' identification badges) along with point-of-transfusion reading devices to verify identity,165,166 as well as other similar approaches.167,168 These tools require investment in information technology, but they can be integrated with other systems such as medication administration.

    • Acute hemolytic transfusion reactions

      2009, Transfusion Medicine and Hemostasis: Clinical and Laboratory Aspects
    • Acute Hemolytic Transfusion Reactions

      2009, Transfusion Medicine and Hemostasis
    View all citing articles on Scopus
    View full text