Failure of bedside ABO testing is still the most common cause of incorrect blood transfusion in the Barcode era.
OBJECTIVE
ABO-incompatible red blood cell (RBC) transfusions are a major risk in transfusion medicine. Identification of factors leading to this hazard is important to improve transfusion safety.


METHODS
All consecutive erroneous ABO-incompatible transfusions occurring from January 1997 to December 2004 at the Charité University Hospital in Berlin, Germany were analysed.


RESULTS
A total of 343,432 RBC units were transfused, and eight patients erroneously received 13 ABO-incompatible RBC concentrates. The most frequent error was incorrect bedside testing (n=7). Intensive care treatment was required in two cases, but there were no fatal mistransfusions. Four patients had no or only mild reactions.


CONCLUSIONS
Mistransfusions are still a considerable risk in transfusion medicine despite quality control systems and electronic data processing. An increase in transfusion safety may require the introduction of further systems, e.g. radio-frequency identification (RFID) tags.
Ahrens
Norbert
N
Institute for Transfusion Medicine, Charité-University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, D-13353 Berlin, Germany. norbert.ahrens@charite.de
Pruss
Axel
A
Kiesewetter
Holger
H
Salama
Abdulgabar
A
D000017:ABO Blood-Group System / Q000032:analysis; D000368:Aged; D001787:Blood Group Incompatibility; D001788:Blood Grouping and Crossmatching; D001330:Electronic Data Processing; D017707:Erythrocyte Transfusion; D005260:Female; D006801:Humans; D008297:Male; D019300:Medical Errors; D008875:Middle Aged; D019095:Point-of-Care Systems; D012307:Risk Factors
D000017:ABO Blood-Group System