To err is human … so how can we prevent all ABO-incompatible transfusions?
Nancy M Dunbar1, Richard M Kaufman1
1Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA.
Insights
Preventable ABO-incompatible red cell transfusions persist despite varied safety measures across the UK, France, and Germany. Human error remains a significant challenge in preventing these transfusion errors.
Area of Science:
- Transfusion Medicine
- Patient Safety
- Hematology
Background:
- ABO-incompatible red cell transfusions pose a significant risk to patient safety.
- Despite established protocols, preventable errors continue to occur in transfusion practices.
Purpose of the Study:
- To analyze the frequencies and causes of ABO-incompatible red cell transfusions.
- To identify persistent challenges in preventing transfusion errors across different countries.
Main Methods:
- Retrospective analysis of ABO-incompatible red cell transfusion data.
- Inclusion of data from the United Kingdom, France, and Germany.
- Review of bedside preventative measures and error identification.
Main Results:
- Preventable ABO-incompatible red cell transfusions are still identified in all three countries.
- Varied strategies for bedside preventative measures have not eliminated these errors.
- Human error is a key factor contributing to the persistence of these mistransfusions.
Conclusions:
- The occurrence of ABO-incompatible red cell transfusions remains an ongoing issue.
- Addressing human error is critical for improving transfusion safety.
- Continued vigilance and improved error-prevention strategies are necessary in transfusion medicine.
Abstract:
Savin et al. report a retrospective analysis of ABO-incompatible red cell transfusions in the United Kingdom, France and Germany. In spite of varied strategies for bedside preventative measures, all three countries continue to identify preventable errors leading to ABO-incompatible red cell transfusions. This report highlights the ongoing challenge of human error as a factor in the persistence of preventable mistransfusions. Commentary on: Savin et al. Frequencies and causes of ABO-incompatible red cell transfusions in France, Germany and the United Kingdom. Br J Haematol 2025; 206:726-734.
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