title: To err is human nature. Can transfusion errors due to human factors ever be eliminated?
abstract: BACKGROUND
  Fatal hemolytic transfusion reaction due to ABO incompatibility occurs mainly as a result of clerical errors. Blood sample drawn from the wrong patient and labeled as another patient's specimen will not be detected by the blood bank unless there is a previous ABO grouping result.
  
  
  METHODS
  In Hong Kong, we had designed a transfusion wristband system--portable barcode scanner system to detect such clerical errors. The system was well accepted by the house staff and had prevented two BO mismatched transfusion. Other current system of patient's identification may have similar results, but the wristband system has the advantages of being simple, inexpensive and easy to implement. The Hong Kong Government is planning to replace the personal identity card for all citizens with an electronic smart card by 2003. If the new card contains the person's detailed red cell phenotypes in digital code, then the phenotypes of all blood donors and admitted patients will be readily available. It is feasible to issue phenotype-matched blood to patients without any need of pre-transfusion testing, therefore eliminating mismatched transfusions for most patients.
  
  
  RESULTS
  Our pilot study of 474 patients showed that the system was safe and up to 98% of admitted patients could be transfused without delays.
  
  
  CONCLUSIONS
  Patients with rare phenotypes, visitors or illegal immigrants may still need pre-transfusion antibody screen, but if most patients can be issued blood units without testings, the potential savings in health care amount to US$14 million/year.
authors.affiliation: Department of Medicine and Therapeutics, Prince of Wales Hospital, 9/F Clinical Sciences Building, Ng Shing Street, Shatin, N.T., Hong Kong, China.
authors.forename: F Y
authors.initials: FY
authors.lastname: Lau
authors.forename: G
authors.initials: G
authors.lastname: Cheng
mesh_terms: D000017:ABO Blood-Group System; D001787:Blood Group Incompatibility; D001330:Electronic Data Processing; D006723:Hong Kong; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D010355:Patient Identification Systems; D010865:Pilot Projects; D011356:Product Labeling; D065227:Transfusion Reaction
chemical_list: D000017:ABO Blood-Group System