Nearly two decades using the check-type to prevent ABO incompatible transfusions: one institution's experience

Review of haemovigilance at the Rabat Regional Blood Transfusion Centre in Morocco (2017-2021)

Introduction

blood transfusion remains an essential therapeutic intervention, but the occurrence of transfusion reactions makes its administration even more complex. Vigilant reporting of such reactions by recipients of blood products is essential for effective haemovigilance. This study aimed to determine the frequency and nature of transfusion reactions.

Methods

conducted over five years (2017-2021) at the Haemovigilance Department of the Rabat Regional Blood Transfusion Centre, this retrospective study exploited incident forms notified by health establishments and data from the regional blood transfusion centre's computer system.

Results

from 1 January 2017 and 31 December 2021, the Rabat Regional Blood Transfusion Centre distributed 435,651 labile blood products to various healthcare establishments, which reported 191 transfusion reactions involving 191 patients. The median age of the patients was 44.3 years, with an overall cumulative incidence of transfusion reactions of 0.44 per 1000 labile blood products delivered. The predominant reactions were non-haemolytic febrile and allergic reactions, accounting for 41.36% and 35.60% respectively. Grade 1 reactions accounted for 87% of all reactions recorded. During the study period, three deaths were recorded, with ABO incompatibility and transfusion-related acute lung injury (TRALI) accounting for two and one case respectively. Transfusion reactions involving erythrocyte components were significantly more frequent than those involving platelet and plasma components.

Conclusion

this study revealed a relatively low incidence of transfusion reactions (0.44%), dominated by non-haemolytic febrile and allergic reactions. Several levels of failure were identified, in particular under-reporting of reactions and inadequate training in transfusion practices and haemovigilance, as well as the need for an effective electronic transfusion reaction reporting system to facilitate reporting and identification of underlying problems and risk factors to improve the quality of transfusion care provided to patients.

How do we ensure a safe ABO recheck process?

BACKGROUND

Collecting a patient's blood in a correctly labeled pretransfusion specimen tube is essential for accurate ABO typing and safe transfusion. Noncompliance with specimen collection procedures can lead to wrong blood in tube (WBIT) incidents with potentially fatal consequences. Recent WBIT events inspired the investigation of how various institutions currently reduce the risk of these errors and ensure accurate ABO typing of patient samples.

MATERIALS AND METHODS

This article describes the techniques employed at various institutions across the United States to mitigate the risk of misidentified pretransfusion patient specimens. Details and considerations for each of these measures are provided.

RESULTS

Several institutions require the order for an ABO confirmation specimen, if indicated, to be generated from the transfusion medicine (TM) laboratory. Others issue a dedicated collection tube that is available exclusively from the TM service. Many institutions employ barcoding for electronic positive patient identification. Some use a combination of these strategies, depending on the locations or service lines from which the specimens are collected.

CONCLUSION

The description of various WBIT mitigation strategies will inform TM services on practices that may be effective at their respective institutions. Irrespective of the method(s) utilized, institutions should continue to monitor and mitigate specimen misidentification errors to promote sustained safe transfusion practices.

How to improve issuing, transfusion and follow-up of blood components in Southern and Eastern Mediterranean countries? A benchmark assessment

To determine the existence of guidelines regarding the appropriate clinical use of blood and blood components, transfusion requests, and blood issuing/reception documents and procedures. The different bedside transfusion organizations/processes and hemovigilance are also analyzed. The ultimate objective is to identify safe potential options in order to improve blood safety at the lowest cost. Data emanating from eight Arabic eastern/southern Mediterranean countries who responded to five surveys were collected and tabulated. National recommendations for the clinical use of blood components especially for hemoglobinopathies are lacking in some countries. In matter of good practices in the prescription, issuing and reception of BCs, efforts were made either on national or local basis. Procedures regarding patient information and ethical issues are still lacking. Almost all Mediterranean countries apply two blood testing procedures on each patient sample. Only Morocco, Tunisia and Algeria perform bed side blood group testing; Egypt and Lebanon perform antibody screen and antiglobulin cross matching universally. Automation for blood testing is insufficiently implemented in almost all countries and electronic release is almost absent. National hemovigilance policy is implemented in Tunisia, Morocco, and Lebanon but the reporting system remains inoperative. Insufficient resources severely hinders the implementation of expensive procedures and programs; however, the present work identifies safe procedures that might save resources to improve other parts in the transfusion process (e.g. electronic release to improve safety in issuing). Moreover, setting up regulations regarding ethics in transfusing recipients along with local transfusion committees are crucially needed to implement hemovigilance in transfusion practice.

Sample collection for pre-transfusion crossmatching: Benefits of using an electronic identification system

BACKGROUND

Transfusion of ABO blood group-mismatched blood or administration to the wrong recipient may result in fatal adverse events. To prevent these types of errors, various strategies have been employed. Recently, we developed a novel sample collection workflow for the pre-transfusion crossmatching test and patient recognition. This study aimed to analyse the usage of the new workflow and improvements in outcomes.

METHODS

We analysed the number of crossmatching and wrong-patient errors among the blood transfusion cases during 3 years of data collection (from August 2018 to July 2021). From May 2021 to July 2021, the new workflow was implemented. Outcomes were calculated according to the department type, patient age and processing time. The sample processing time was defined as the time from placing the order to lab arrival.

RESULTS

The new workflow utilisation increased from 50.7% to 80.3% and wrong-patient errors decreased annually. The new workflow was used for more adults (3001/3680 samples, 81.5%) than paediatric cases (345/522 samples, 65.5%; p < 0.001) and in general wards than in the emergency room or intensive care unit. The sample processing time differed according to ward type and timing of the request (day: 28.80, 2.43-3889.43 min, night: 3.36, 2.72-1671.47 min; p < 0.001).

CONCLUSION

Wrong-patient errors were reduced without increasing sample-processing time after introducing the new workflow which included using an electronic identification system. The time needed for the blood processing differed according to the ward type, patient age, and timing of the request. Patient safety can be promoted by managing these factors and using an electronic identification system.

Wrong Tissue in Block

OBJECTIVES

Maintaining specimen identity during surgical pathology tissue processing is critical. Epic Beaker Laboratory Information System requires sequential scanning of specimen label and grossed blocks (block confirmation) to ensure specimen identity. We report our institution's experience with wrong tissue in block (WTIB) grossing errors before and after adopting block confirmation.

METHODS

During the first 18 months of Beaker implementation, block confirmation was not required. We then mandated block confirmation for a 3-month period. To ensure compliance, we then built a "hard stop" feature that prevents scanning any unconfirmed blocks onto a packing list. We reviewed WTIB incidents pre- and postimplementation of these solutions.

RESULTS

Before using block confirmation, we had WTIB incidents involving 17 (0.043%) of 38,848 cases. When we mandated block confirmation use, we had WTIB involving 2 (0.043%) of 4,646 cases. After implementing the hard stop feature, we had WTIB incidents involving 2 (0.005%) of 42,411 cases. Overall, there was an 88.4% (0.043% vs 0.005%; P < .001) reduction in WTIB incidents using block confirmation with a hard stop.

CONCLUSIONS

Beaker is a customizable platform that can be tailored to a laboratory's workflow. By using barcoding, implementing custom-built features, and improving workflow protocols, we significantly reduced WTIB errors.

Prevalence of Near-miss Events of Transfusion Practice and Its Associated Factors amongst House Officers in a Teaching Hospital

Objectives

A near miss in transfusion practice is defined as a deviation from standard procedures discovered before transfusion and can lead to a transfusion error. Information on near-miss events provides pivotal data on areas of improvement to prevent actual errors in the future. Our study sought to determine the prevalence and rate of near-miss events and their associated factors amongst house officers (HO) in Hospital Universiti Sains Malaysia.

Methods

The initial part of this study is a descriptive cross-sectional study involving data collection from all requests sent for group, screen, and hold (GSH) and group and cross match (GXM) tests from 2011 to 2017. The association between sociodemographic, workplace, and experience factors with near-miss events amongst HO was analyzed with a case-control study using logistic regression.

Results

We reported 83 near-miss events with a prevalence of 0.034% (95% confidence interval 0.027–0.042). The rate of near-miss events was one in every 2916 requests. The mean reporting rate was 11.9 events per year. Clinical near miss predominated at 89.2% compared to 10.8% laboratory near miss. Mislabeled events (33.7%) were more than miscollected events (10.8%). HO were implicated with most events (83.1%). Most events were predominantly in the medical and obstetrics and gynecology wards amounting to 31.3% each. We found a significant association between the ages of HO with near-miss events.

Conclusions

The prevalence of near-miss events in our hospital was relatively low. Our study has shown areas for improvement include improving sampling practices in clinical areas, adequate training of laboratory technicians, and providing proper transfusion education. Interventions such as encouraging compliance to guidelines and training in clinical and laboratory areas to minimize the risk of mistransfusion should be considered.

Heterogeneity in Approaches for Switching From Universal to Patient ABO Type-Specific Blood Components During Massive Hemorrhage: An International Survey and Review of the Literature

CONTEXT.—

ABO mistransfusions are rare and potentially fatal events. Protocols are required by regulatory agencies to minimize this risk to patients, but how these are applied in the context of massive transfusion protocols (MTPs) is not specifically defined.

OBJECTIVE.—

To evaluate the approaches used by transfusion services for switching from universally compatible to patient ABO type-specific blood components during massive hemorrhage.

DESIGN.—

We added 1 supplemental multiple-choice question to address the study objective to the 2019 College of American Pathologists proficiency test J-survey (J-A 2019). We also reviewed the available literature regarding this topic.

RESULTS.—

A total of 881 laboratories responded to the supplemental question. Approximately 80% (704 of 881) report a policy for ABO-type switching during an MTP. Policies varied considerably between responding laboratories, but most (384 of 704, 55%) required 2 ABO types to match before switching from universal to recipient-specific blood components. Additional safety measures used in a minority of these protocols included reaction strength criteria (103 of 704, 15%), on-call medical director approval (41 0f 704, 5.8%), universal red cell unit number limits (12 of 704, 1.7%), or the presence of a mixed field (3 of 704, 0.4%).

CONCLUSIONS.—

This survey reveals that significant heterogeneity exists regarding the available approaches for ABO-type switching during an MTP. Specific expert guidance regarding this issue is very limited, and best practices have not yet been established or rigorously investigated.

Registration errors among patients receiving blood transfusions: a national analysis from 2008 to 2017

BACKGROUND AND OBJECTIVES

The key first step for a safe blood transfusion is patient registration for identification and linking to past medical and transfusion history. In Canada, any deviation from standard operating procedures in transfusion is an error voluntarily reportable to a national database (Transfusion Error Surveillance System [TESS]). We used this database to characterize the subset of registration-related errors impacting transfusion care, including where, when and why the errors occurred, and to identify frequent high-risk errors.

MATERIALS AND METHODS

A retrospective analysis was conducted on transfusion errors reported to TESS by sentinel reporting sites relating to patient registration and patient armbands, between 2008 and 2017. Free-text comments describing the error were coded to further categorize into common error types. The number of specimens received in the transfusion laboratory was used as the denominator for rates to allow for comparison between hospital sites.

RESULTS

Five hundred and fifty-four registration errors were reported from 10 hospitals, for a global error rate of 5·4/10 000 samples (median 5·0 [interquartile range 3·7-7·0]). The potential severity was high in 85·7% of errors (n = 475). The patient experienced a consequence in 10·8% of errors (n = 60), but none resulted in patient harm. Rates varied widely and differed by nature across sites. Errors most commonly occurred in outpatient clinics or procedure units (n = 160, 28·8%) and in emergency departments (n = 130, 23·5%).

CONCLUSION

Registration errors affect transfusion at every step and location in the hospital and are commonly high risk. Further research into common root causes is warranted to identify preventative strategies.

Risk factors for hemolytic transfusion reactions resulting from ABO and minor red cell antigen incompatibility: From mislabeled samples to stem cell transplant and sickle cell disease

Advances in laboratory testing, pathogen reduction and donor qualification have dramatically reduced the risk of acquiring an infection from a blood transfusion. Despite this progress, the most feared complication of transfusion - a hemolytic reaction due to incompatibility between donor and recipient - remains, with essentially no recent progress in the prevention or recognition of this rare but frequently lethal complication. Herein, the role that compatibility testing and transfusion practice play in the occurrence of acute hemolysis are described, with a special emphasis on clinical scenarios confer an increased risk of a severe hemolytic reaction in response to red blood cell or platelet transfusion. In addition, the signs and symptoms of a severe hemolytic reaction are summarized, along with the initial approach to clinical management.

Evaluation of a two-sample process for prevention of ABO mistransfusions in a high volume academic hospital

Background

Acute haemolytic transfusion reactions due to ABO incompatible blood transfusion remain a leading cause of transfusion-associated morbidity and mortality in the USA. Erroneous patient identification and specimen labelling account for many errors that lead to ABO mistransfusions; these errors are largely preventable.

Methods

Our hospital requires a two-sample process of ABO/Rh typing prior to transfusion. Both samples must be drawn independently. To prevent simultaneous sample draw, our second sample tube has a unique pink top that is only available from the blood bank and can only be sent to the patient’s floor once the first sample arrives in the lab. We performed an audit of this process from 19 March to 30 July 2014 and 19 March to 30 July 2015.

Results

We reviewed type and crossmatch orders for 2702 new patients during the audit period and 824 patients (30.5%) required transfusion. All patients evaluated received compatible blood, and no mistransfusions were recorded using this method. Three per cent of testing was performed incorrectly, which safely defaulted to giving type O blood.

Conclusions

The two-sample protocol used by our institution can decrease the risk of mistransfusion. Our protocol was relatively inexpensive, safe, efficient and practical for adaptation by other hospitals.

Sample collection and sample handling errors submitted to the transfusion error surveillance system, 2006 to 2015

BACKGROUND

In Canada, transfusion-related errors are voluntarily reported to a tracking system with the goal to systematically improve transfusion safety. This report provides an analysis of sample collection (SC) and sample handling (SH) errors from this national error-tracking system.

STUDY DESIGN AND METHODS

Errors from 2006 to 2015 from 23 participating sites were extracted. A survey was conducted to obtain information regarding institutional policies. Samples received in the blood bank were used to calculate rates. "Wrong blood in tube" (WBIT) errors are blood taken from wrong patient and labeled with intended patient's information, or blood taken from intended patient but labeled with another patient's information.

RESULTS

A total of 42,363 SC and 14,666 SH errors were reported. Predefined low-severity (low potential for harm) and high-severity errors (potential for fatal outcomes) increased from 2006 to 2015 (low SC, SH: 13-27, 3-12 per 1000; high SC, SH: 1.9-3.7, 0.5-2.0 per 1000). The WBIT rate decreased from 12 to 5.8 per 10,000 between 2006 and 2015 (p < 0.0001). The overall WBIT rate was 6.2 per 10,000, with variability by site (median, 0.3 per 10,000; range, 0-17 per 10,000). Sites with error detection mechanisms, such as regrouping second sample requirements, had lower error rates than sites that did not (SC, SH: 12, 1 per 1000 samples vs. 17, 3 per 1000 samples; p < 0.0001).

CONCLUSION

WBIT rates decreased significantly. Low-severity error rates are climbing likely due to increased ascertainment and reporting. Prevention studies are necessary to inform changes to blood transfusion standards to eliminate these errors.

Using Blood Donor-Derived ABO and RhD Blood Groups Helps to Detect Wrong Blood in Tube Errors in Recipients

Background

Comparing the ABO and RhD group of a recipient's current pre-transfusion sample against their historical group is an important means of detecting wrong blood in tube (WBIT) errors. This study investigated the utility of using the donor ABO and RhD group as the historical check for recipients.

Methods

A single database stores serological information on blood donors, pregnant women, and patients throughout southern Denmark. A donor ABO and RhD group can be the historical blood group should that donor later require a transfusion. This database was searched to determine how often the ABO and RhD group on a recipient's current pre-transfusion sample was discrepant with their historical donor-derived blood group.

Results

During about 21 years, ABO and RhD groupings were performed on 76,455 blood donors and on 424,697 patients. There were 13,630/424,697 (3.2%) patients who had their donor-derived ABO and RhD group used as the historical comparison with the current sample; 6/13,630 (0.04%) of the current pre-transfusion samples on these patients were discrepant with the donor-derived historical group because of WBIT errors. Seven other discrepancies with the donor-derived blood group were also found.

Conclusion

Accessing the donor-derived ABO and RhD group can be an important safeguard against WBIT-mediated mistransfusions.

Determination of health workers' level of knowledge about blood transfusion

OBJECTIVE:

This study was conducted to determine the knowledge level of healthcare workers about blood transfusion.

METHODS:

The study was conducted between October 1, 2015 and November 2, 2015 with 100 healthcare personnel working in a training and research hospital. A survey consisting of 19 questions based on the literature was prepared and administered. In addition to descriptive statistical methods (frequency), Fisher’s exact chi-square test and Yates’ correction for continuity were used to compare qualitative data. Significance was assessed at p<0.05.

RESULTS:

Of the total, 52% of the participants were ≤29 years of age and 94% were women. In all, 71% were nurses and 42% had been working at the hospital for 2 to 5 years. Seventy-nine percent indicated that they had been trained in blood and blood product transfusion, 86% stated that transfusions were performed to replace deficient blood volume, and 95% responded that blood was to be requested by a physician, and 97% indicated that informed consent of the patient should be obtained for a blood transfusion. In all, 78% of respondents identified crossmatching as the final check for ABO compatibility. With respect to blood unit quality, 90% of the respondents stated that they would return blood if the label could not be read and 98% would reject the product if the integrity of the blood bag was compromised or of the blood had a cloudy or foamy appearance. In the event of a patient experiencing fever and shock, 96% of the survey participants indicated that they would consider that it could be a reaction to a blood transfusion. The need to confirm the patient’s identity and the type of blood products was corroborated by 91%, and 85% agreed that no other medication should be added to the blood to be transfused. Furthermore, 88% of the study participants approved of continuous training regarding the transfusion of blood and blood products.

CONCLUSION:

According to the results of this research, while the knowledge of the healthcare professionals surveyed was adequate, standardization was lacking. In this respect, it may be advisable to conduct further studies on blood transfusion practices, and to provide additional in-service training to ensure patient safety and avoid medical errors.

The Impact of an Electronic Ordering System on Blood Bank Specimen Rejection Rates

OBJECTIVES

To evaluate the impact that an electronic ordering system has on the rate of rejection of blood type and screen testing samples and the impact on the number of ABO blood-type discrepancies over a 4-year period.

METHODS

An electronic ordering system was implemented in May 2011. Rejection rates along with reasons for rejection were tracked between January 2010 and December 2013.

RESULTS

A total of 40,104 blood samples were received during this period, of which 706 (1.8%) were rejected for the following reasons: 382 (54.0%) unsigned samples, 235 (33.0%) mislabeled samples, 57 (8.0%) unsigned requisitions, 18 (2.5%) incorrect tubes, and 14 (1.9%) ABO discrepancies. Of the samples, 2.5% were rejected in the year prior to implementing the electronic ordering system compared with 1.2% in the year following implementation ( P  < .0001).

CONCLUSIONS

Our data demonstrate that implementation of an electronic ordering system significantly decreased the rate of blood sample rejection.

Transfusion reactions: prevention, diagnosis, and treatment

Blood transfusion is one of the most common procedures in patients in hospital so it is imperative that clinicians are knowledgeable about appropriate blood product administration, as well as the signs, symptoms, and management of transfusion reactions. In this Review, we, an international panel, provide a synopsis of the pathophysiology, treatment, and management of each diagnostic category of transfusion reaction using evidence-based recommendations whenever available.

Unreliable patient identification warrants ABO typing at admission to check existing records before transfusion

BACKGROUND AND OBJECTIVES

This study describes patient identification errors leading to transfusional near-misses in blood issued by the Alps Mediterranean French Blood Establishment (EFSAM) to Marseille Public Hospitals (APHM) over an 18-month period. The EFSAM consolidates 14 blood banks in southeast France. It supplies 149 hospitals and maintains a centralized database on ABO types used at all area hospitals. As an added precaution against incompatible transfusion, the APHM requires ABO testing at each admission regardless of whether the patient has an ABO record. The study goal was to determine if admission testing was warranted.

MATERIALS AND METHODS

Discrepancies between ABO type determined by admission testing and records in the centralized database were investigated. The root cause for each discrepancy was classified as specimen collection or patient admission error. Causes of patient admission events were further subclassified as namesake (name similarity) or impersonation (identity fraud).

RESULTS

The incidence of ABO discrepancies was 1:2334 including a 1:3329 incidence of patient admission events. Impersonation was the main cause of identity events accounting for 90.3% of cases. The APHM's ABO control policy prevented 19 incompatible transfusions. In relation to the 48,593 packed red cell units transfused, this would have corresponded to a risk of 1:2526.

CONCLUSION

Collecting and storing ABO typing results in a centralized database is an essential public health tool. It allows crosschecking of current test results with past records and avoids redundant testing. However, as patient identification remains unreliable, ABO typing at each admission is still warranted to prevent transfusion errors.

Wrong blood in tube - potential for serious outcomes: can it be prevented?

'Wrong blood in tube' (WBIT) errors, where the blood in the tube is not that of the patient identified on the label, may lead to catastrophic outcomes, such as death from ABO-incompatible red cell transfusion. Transfusion is a multistep, multidisciplinary process in which the human error rate has remained unchanged despite multiple interventions (education, training, competency testing and guidelines). The most effective interventions are probably the introduction of end-to-end electronic systems and a group-check sample for patients about to receive their first transfusion, but neither of these eradicates all errors. Further longer term studies are required with assessment before and after introduction of the intervention. Although most focus has been on WBIT in relation to blood transfusion, all pathology samples should be identified and linked to the correct patient with the same degree of care. Human factors education and training could help to increase awareness of human vulnerability to error, particularly in the medical setting where there are many risk factors.

Pathology consultation on electronic crossmatch

OBJECTIVES

The full crossmatch is traditionally the final step in compatibility testing, acting as a serologic double check for ABO compatibility and unexpected RBC antibodies. In this review, we discuss the development of electronic crossmatch (EXM), an approach for determining when EXM can be used, and its strengths and weaknesses.

METHODS

Because EXM relies on highly sensitive screening assays, antibodies are frequently encountered whose clinical significance must be investigated and interpreted. Our approach is to obtain further history, perform enhanced tube testing, and consider tests of immune reactivity or RBC survival.

RESULTS

For those without clinically significant antibodies, we found two alternatives: immediate-spin crossmatch (IS XM) and EXM. IS XM is prone to error related to serologic interference, whereas EXM depends on the accuracy of the sample label, accurate data entry, and informatics to avoid errors.

CONCLUSION

EXM is an alternative to the serologic test in patients who have no clinically significant antibodies.

Interventions to reduce wrong blood in tube errors in transfusion: a systematic review

This systematic review addresses the issue of wrong blood in tube (WBIT). The objective was to identify interventions that have been implemented and the effectiveness of these interventions to reduce WBIT incidence in red blood cell transfusion. Eligible articles were identified through a comprehensive search of The Cochrane Library, MEDLINE, EMBASE, Cinahl, BNID, and the Transfusion Evidence Library to April 2013. Initial search criteria were wide including primary intervention or observational studies, case reports, expert opinion, and guidelines. There was no restriction by study type, language, or status. Publications before 1995, reviews or reports of a secondary nature, studies of sampling errors outwith transfusion, and articles involving animals were excluded. The primary outcome was a reduction in errors. Study characteristics, outcomes measured, and methodological quality were extracted by 2 authors independently. The principal method of analysis was descriptive. A total of 12,703 references were initially identified. Preliminary secondary screening by 2 reviewers reduced articles for detailed screening to 128 articles. Eleven articles were eventually identified as eligible, resulting in 9 independent studies being included in the review. The overall finding was that all the identified interventions reduced WBIT incidence. Five studies measured the effect of a single intervention, for example, changes to blood sample labeling, weekly feedback, handwritten transfusion requests, and an electronic transfusion system. Four studies reported multiple interventions including education, second check of ID at sampling, and confirmatory sampling. It was not clear which intervention was the most effective. Sustainability of the effectiveness of interventions was also unclear. Targeted interventions, either single or multiple, can lead to a reduction in WBIT; but the sustainability of effectiveness is uncertain. Data on the pre- and postimplementation of interventions need to be collected in future trials to demonstrate effectiveness, and comparative studies are needed of different interventions.

Quality standards and samples in genetic testing

The most critical performance indicator for medical laboratories is the delivery of accurate test results. In any laboratory, there is always the possibility that random or systematic errors may occur and place human health and welfare at risk. Laboratory quality assurance programmes continue to drive improvements in analytical accuracy. The most rigorously scrutinised data on laboratory errors, which come from transfusion medicine, reveal that the incidence of analytical errors has fallen to levels where most of the residual risk is now found in preanalytical links in the chain from patient to result, particularly activities associated with ordering of tests and sample collection. This insight is important for genetic testing because, like pretransfusion testing of patients with unknown blood groups, a substantial proportion of genotyping results cannot be immediately verified. An increasing number of clinical decisions, associated personal and social choices, and legal outcomes are now influenced by genetic test results in the absence of other confirmatory data. An incorrect test result may lead to unnecessary and irreversible interventions, which may in themselves have associated risks for the patient, inaccurate risk assessment regarding the disease, missed opportunities for disease prevention or even wrongful conviction in a court of law. Unfortunately, there is limited information available about the risk of preanalytical errors associated with, and few published guidelines regarding, sample collection for genetic testing. The growing number and range of important decisions made on the basis of genetic findings warrant a reappraisal of current standards to minimise risks in genetic testing.

Managing transfusion service quality

CONTEXT

Providing blood products for transfusions is a complex process subject to errors both within and outside the transfusion service. Transfusion-related errors can have grave consequences for the patient undergoing transfusion. As with many processes performed within health care systems, there is an expectation of error-free practice. Although this is an unobtainable goal, a focused quality-management plan, employing a medical event reporting system in a just working environment, can effect measurable system-quality improvement.

OBJECTIVE

To illustrate the intrinsic value of quality-improvement activities through discussion of examples of quality misadventures from our transfusion service during the past 20 years.

DATA SOURCES

Examples of quality-improvement activities were extracted from our quality-system archives. The published literature on transfusion quality was reviewed.

CONCLUSIONS

Active reporting, structured investigation, and systematic resolution of transfusion-related errors are effective methods for improving and maintaining transfusion quality.

Blood bank safety practices: mislabeled samples and wrong blood in tube--a Q-Probes analysis of 122 clinical laboratories

CONTEXT

Although a rare occurrence, ABO incompatible transfusions can cause patient morbidity and mortality. Up to 20% of all mistransfusions are traced to patient misidentification and/or sample mislabeling errors that occur before a sample arrives in the laboratory. Laboratories play a significant role in preventing mistransfusion by identifying wrong blood in tube and rejecting mislabeled samples.

OBJECTIVES

To determine the rates of mislabeled samples and wrong blood in tube for samples submitted for ABO typing and to survey patient identification and sample labeling practices and sample acceptance policies for ABO typing samples across a variety of US institutions.

DESIGN

One hundred twenty-two institutions prospectively reviewed inpatient and outpatient samples submitted for ABO typing for 30 days. Labeling error rates were calculated for each participant and tested for associations with institutional demographic and practice variable information. Wrong-blood-in-tube rates were calculated for the 30-day period and for a retrospective 12-month period. A concurrent survey collected institution-specific sample labeling requirements and institutional policies regarding the fate of mislabeled samples.

RESULTS

For all institutions combined, the aggregate mislabeled sample rate was 1.12%. The annual and 30-day wrong-blood-in-tube aggregate rates were both 0.04%. Patient first name, last name, and unique identification number were required on the sample by more than 90% of participating institutions; however, other requirements varied more widely.

CONCLUSIONS

The rates of mislabeled samples and wrong blood in tube for US participants in this study were comparable to those reported for most European countries. The survey of patient identification and sample labeling practices and sample acceptance policies for ABO typing samples revealed both practice uniformity and variability as well as significant opportunity for improvement.

Blood still kills: six strategies to further reduce allogeneic blood transfusion-related mortality

After reviewing the relative frequency of the causes of allogeneic blood transfusion-related mortality in the United States today, we present 6 possible strategies for further reducing such transfusion-related mortality. These are (1) avoidance of unnecessary transfusions through the use of evidence-based transfusion guidelines, to reduce potentially fatal (infectious as well as noninfectious) transfusion complications; (2) reduction in the risk of transfusion-related acute lung injury in recipients of platelet transfusions through the use of single-donor platelets collected from male donors, or female donors without a history of pregnancy or who have been shown not to have white blood cell (WBC) antibodies; (3) prevention of hemolytic transfusion reactions through the augmentation of patient identification procedures by the addition of information technologies, as well as through the prevention of additional red blood cell alloantibody formation in patients who are likely to need multiple transfusions in the future; (4) avoidance of pooled blood products (such as pooled whole blood-derived platelets) to reduce the risk of transmission of emerging transfusion-transmitted infections (TTIs) and the residual risk from known TTIs (especially transfusion-associated sepsis [TAS]); (5) WBC reduction of cellular blood components administered in cardiac surgery to prevent the poorly understood increased mortality seen in cardiac surgery patients in association with the receipt of non-WBC-reduced (compared with WBC-reduced) transfusion; and (6) pathogen reduction of platelet and plasma components to prevent the transfusion transmission of most emerging, potentially fatal TTIs and the residual risk of known TTIs (especially TAS).

Proceedings of a Consensus Conference: pathogen inactivation-making decisions about new technologies

Significant progress has been made in reducing the risk of pathogen transmission to transfusion recipients. Nonetheless, there remains a continuing risk of transmission of viruses, bacteria, protozoa, and prions to recipients. These include many of the viruses for which specific screening tests exist as well as pathogens for which testing is currently not being done, including various species of bacteria, babesiosis, variant Creutzfeld-Jacob disease, hepatitis A virus, human herpes virus 8, chikungunya virus, Chagas disease, and malaria. Pathogen inactivation (PI) technologies potentially provide an additional way to protect the blood supply from emerging agents and also provide additional protection against both known and as-yet-unidentified agents. However, the impact of PI on product quality and recipient safety remains to be determined. The purpose of this consensus conference was to bring together international experts in an effort to consider the following issues with respect to PI: implementation criteria; licensing requirements; blood service and clinical issues; risk management issues; cost-benefit impact; and research requirements. These proceedings are provided to make available to the transfusion medicine community the considerable amount of important information presented at this consensus conference.