Human errors in manual techniques for ABO/D grouping are associated with potentially lethal outcomes.
ABO grouping
SHOT
automation
blood
laboratory
testing
transfusion
Journal
Transfusion medicine (Oxford, England)
ISSN: 1365-3148
Titre abrégé: Transfus Med
Pays: England
ID NLM: 9301182
Informations de publication
Date de publication:
Aug 2019
Aug 2019
Historique:
received:
17
05
2018
revised:
17
05
2018
accepted:
06
06
2019
pubmed:
17
7
2019
medline:
7
2
2020
entrez:
17
7
2019
Statut:
ppublish
Résumé
To review if ABO/D grouping errors are more likely to occur with manual intervention compared to automation. Human errors in manual pre-transfusion testing may result in ABO/D-incompatible transfusions and catastrophic outcomes. Accurate ABO/D grouping is a critical part of pre-transfusion testing. This was a retrospective analysis of reports made to Serious Hazards of Transfusion (SHOT) between January 2004 and December 2016 where ABO/D grouping errors led to the transfusion of an incorrect blood component to review if errors are more likely to occur with manual intervention compared to automation. In 148 of 158 (93%) ABO/D grouping errors, manual intervention took place. In the remaining 10, causes were not reported. No errors occurred with full automation. Interpretation errors occurred in 86 of 148 (58%) and 42 of 148 (28%) transcription errors, and in 20 of 148, wrong or no samples were selected. Of 148 errors, 21 (14%) resulted in ABO-incompatible transfusion, with one death in 2004 due to an interpretation error in a manual ABO group. In 30 of 148 (20%), D-positive red cells were given to D-negative recipients, where three women of child-bearing potential became sensitised and developed anti-D. ABO grouping errors have reduced from 18 of 539 (3%) of total reports analysed in 2004 (3·3%) to 3 of 3091 (0·10%) in 2016. Where manual testing cannot be avoided, results should be confirmed using automated techniques as soon as possible, and a back-up process should be available 24/7. SHOT data confirm that manual interventions are prone to human error, especially in transcription and interpretation, and demonstrate a continuing need for appropriate serological knowledge and understanding by transfusion laboratory staff to underpin safety provided by automation and information technology (IT).
Sections du résumé
AIMS/OBJECTIVES
OBJECTIVE
To review if ABO/D grouping errors are more likely to occur with manual intervention compared to automation.
BACKGROUND
BACKGROUND
Human errors in manual pre-transfusion testing may result in ABO/D-incompatible transfusions and catastrophic outcomes. Accurate ABO/D grouping is a critical part of pre-transfusion testing.
METHODS
METHODS
This was a retrospective analysis of reports made to Serious Hazards of Transfusion (SHOT) between January 2004 and December 2016 where ABO/D grouping errors led to the transfusion of an incorrect blood component to review if errors are more likely to occur with manual intervention compared to automation.
RESULTS
RESULTS
In 148 of 158 (93%) ABO/D grouping errors, manual intervention took place. In the remaining 10, causes were not reported. No errors occurred with full automation. Interpretation errors occurred in 86 of 148 (58%) and 42 of 148 (28%) transcription errors, and in 20 of 148, wrong or no samples were selected. Of 148 errors, 21 (14%) resulted in ABO-incompatible transfusion, with one death in 2004 due to an interpretation error in a manual ABO group. In 30 of 148 (20%), D-positive red cells were given to D-negative recipients, where three women of child-bearing potential became sensitised and developed anti-D. ABO grouping errors have reduced from 18 of 539 (3%) of total reports analysed in 2004 (3·3%) to 3 of 3091 (0·10%) in 2016.
CONCLUSIONS
CONCLUSIONS
Where manual testing cannot be avoided, results should be confirmed using automated techniques as soon as possible, and a back-up process should be available 24/7. SHOT data confirm that manual interventions are prone to human error, especially in transcription and interpretation, and demonstrate a continuing need for appropriate serological knowledge and understanding by transfusion laboratory staff to underpin safety provided by automation and information technology (IT).
Substances chimiques
ABO Blood-Group System
0
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
262-267Subventions
Organisme : SHOT scheme: NHSBT
Organisme : SNBTS
Organisme : WBS
Organisme : NIBTS
Organisme : Serious Hazards of Transfusion Steering Group
Organisme : Working Expert Group
Informations de copyright
© 2019 British Blood Transfusion Society.
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