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Human errors in manual techniques for ABO/D grouping are associated with potentially lethal outcomes
Transfusion Medicine (Oxford, England)
|July 17, 2019
Summary
Manual ABO/D grouping errors in pre-transfusion testing are significantly more common than automated methods, leading to transfusion complications. Automation and robust protocols are crucial for patient safety in blood transfusion services.
Area of Science:
- Transfusion Medicine
- Clinical Pathology
- Patient Safety
Background:
- Accurate ABO/D grouping is vital for safe pre-transfusion testing.
- Human errors in manual testing can lead to ABO/D-incompatible transfusions with severe consequences.
Purpose of the Study:
- To compare the incidence of ABO/D grouping errors between manual intervention and automation in pre-transfusion testing.
- To identify the types and causes of errors associated with manual ABO/D grouping.
Main Methods:
- Retrospective analysis of Serious Hazards of Transfusion (SHOT) reports from January 2004 to December 2016.
- Focused on ABO/D grouping errors leading to incorrect blood component transfusion.
Main Results:
- Manual intervention was implicated in 93% of ABO/D grouping errors.
- Interpretation and transcription errors were common in manual processes.
- No errors were reported with fully automated systems.
- ABO/D grouping errors have significantly decreased over the study period.
Conclusions:
- Manual ABO/D grouping processes are highly prone to human error, particularly in transcription and interpretation.
- Automation significantly reduces ABO/D grouping errors, enhancing patient safety.
- Continuous training in serological knowledge is essential for laboratory staff to complement automation.
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