Procedural errors in antibody identification.
In experimental studies of students and line technologists performing antibody identification procedures, both groups made errors. These errors included, at times, either failing to identify an antibody or misidentifying the specficity(ies)A. prospective study was undertaken to identify errors made in a laboratory setting. Errors were classified as 1) failing to follow protocol (procedural error) or 2) arriving at the wrong answer (misidentification error). Over a 1-year period, 1,057 workups were reviewed. There were 41 (3.88%) procedural errors and no misidentification errors. In 25 workups (61% of errors), the selection of cells m rule out underlying alloantibody(ies) was in error. The remaining 16 involved various "slips" (minor mistakes or memory lapses) and clerical errors. Based on an analysis of the probable causes of these errors, potential solutions include 1) developing computer aids to detect "rule-out" errors or missing tests results; 2) providing timely, careful review of workups before transfusion; and 3) designing better panel layout and cell selection.
Strohm
P L
PL
Ohio State University Hospitals, Columbus, OH, USA.
Smith
P J
PJ
Fraser
J M
JM
Smith
J W
JW
Rudmann
S V
SV
Svirbely
J R
JR
Miller
T E
TE
Blazina
J F
JF
Kennedy
M S
MS