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Misinterpretation of blood group and antibody screen leading to serious errors in RhD immunoglobulin administration:

Christine Akers1,2, Helen Savoia3, Stefan Kane3

  • 1Blood Matters, Department of Health and Human Services, Serious Transfusion Incident Reporting Program, Melbourne, Victoria, Australia.

The Australian & New Zealand Journal of Obstetrics & Gynaecology
|September 7, 2018
PubMed

The Serious Transfusion Incident Reporting program (STIR) commenced haemovigilance in relation to RhD immunoglobulin (Ig) administration in 2015. During two years of reporting, 21 reports relating to RhD Ig administration were received. Thirty-three percent (7/21) were related to omission of RhD Ig, putting women at risk of RhD alloimmunisation and adverse consequences in future pregnancies. A recent case reported to STIR highlights poor communication and misinterpretation of pathology results leading to significant morbidity from haemolysis in the fetus. STIR makes recommendations related to education of staff and communication between clinical and laboratory staff to improve the safety of patient care.

Keywords:
RhD immunoglobulinanti-Dhaemovigilance

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