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A blood bank incorrectly informed a donor of HIV reactivity due to a data misinterpretation. Manual record review revealed the error, highlighting the continued importance of traditional record-keeping alongside digital systems.

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Area of Science:

  • Blood banking and transfusion medicine
  • Clinical diagnostics and laboratory medicine
  • Public health and infectious disease screening

Background:

  • Effective donor notification and post-donation counseling are critical blood bank functions.
  • Accurate communication of test results, including Human Immunodeficiency Virus (HIV) screening, is paramount for donor care.
  • Blood banks utilize both Enzyme-Linked Immunosorbent Assay (ELISA) and Nucleic Acid Testing (NAT) for sensitive HIV detection.

Observation:

  • A young female voluntary blood donor was initially informed of reactive HIV results via both ELISA and NAT.
  • Upon returning for follow-up counseling, repeat testing showed negative results for HIV.
  • No high-risk behavior history was identified during the counseling session.

Findings:

  • A review of the Hospital Information System (HIS) initially seemed to confirm the reactive results.
  • Subsequent retrieval and examination of manual donor records and questionnaires revealed a misinterpretation of data by the counselor.
  • The HIS data, while consistent with demographic profiles, was incorrectly interpreted, leading to the false notification.

Implications:

  • This case underscores the critical importance of accurate data interpretation in clinical settings, even with advanced information technology.
  • It highlights potential pitfalls in electronic health record (EHR) systems and the necessity for robust verification processes.
  • The study emphasizes that despite technological advancements, meticulous manual record review remains a crucial 'gold standard' for ensuring data integrity and preventing diagnostic errors in blood banking.