Switching donor cells as a major source of error in compatibility testing

Area of Science:

• Transfusion Medicine
• Clinical Laboratory Science
• Patient Safety

Background:

• Transfusion of incompatible blood poses a significant risk of fatality.
• Improper patient identification is a commonly cited cause of transfusion errors.
• A previously unreported error source during laboratory testing was investigated.

Purpose of the Study:

• To identify and quantify errors in blood compatibility testing.
• To analyze the frequency of donor unit switching during proficiency testing.
• To assess the impact of laboratory errors on transfusion safety.

Main Methods:

• Retrospective analysis of external proficiency testing program results.
• Evaluation of major errors assigned to laboratories for switching donor units.
• Analysis of data from Level A (extended) and Level B (basic) testing laboratories.

Main Results:

• Switching of donor cells during compatibility testing accounted for approximately one-third (31.3%) of major errors.
• Level A laboratories committed 38.9% of their major errors due to switching donor units.
• Level B laboratories committed 26.7% of their major errors due to switching donor units.

Conclusions:

• Switching donor cells during compatibility testing is a critical and underreported source of laboratory error.
• This error can lead to the transfusion of incompatible blood units, jeopardizing patient safety.
• Improved laboratory protocols and vigilance are necessary to prevent donor cell switching and ensure transfusion safety.