Consecutive national surveys of ABO-incompatible blood transfusion in Japan.
OBJECTIVE
Morbidity and mortality from ABO-incompatible transfusion persist as consequences of human error. Even so, insufficient attention has been given to improving transfusion safety within the hospital.


METHODS
National surveys of ABO-incompatible blood transfusions were conducted by the Japanese Society of Blood Transfusion, with support from the Ministry of Health, Labor and Welfare. Surveys concluded in 2000 and 2005 analysed ABO-incompatible transfusion data from the previous 5 years (January 1995 to December 1999 and January 2000 to December 2004, respectively). The first survey targeted 777 hospitals and the second, 1355 hospitals. Data were collected through anonymous questionnaires.


RESULTS
The first survey achieved a 77.4% response rate (578 of 777 hospitals). The second survey collected data from 251 more hospitals, but with a lower response rate (61.2%, or 829 of 1355 hospitals). The first survey analysed 166 incidents from 578 hospitals, vs. 60 incidents from 829 hospitals in the second survey. The main cause of ABO-incompatible transfusion was identification error between patient and blood product: 55% (91 of 166) in the first survey and 45% (27 of 60) in the second. Patient outcomes included nine preventable deaths from 1995 to 1999, and eight preventable deaths from 2000 to 2004.


CONCLUSIONS
Misidentification at the bedside persists as the main cause of ABO-incompatible transfusion.
Fujii
Y
Y
Department of Blood Transfusion, Yamaguchi University Hospital, Yamaguchi, Japan. yfujii-ygc@umin.ac.jp
Shibata
Y
Y
Miyata
S
S
Inaba
S
S
Asai
T
T
Hoshi
Y
Y
Takamatsu
J
J
Takahashi
K
K
Ohto
H
H
Juji
T
T
Sagawa
K
K
D000017:ABO Blood-Group System / Q000032:analysis*; D000068:Accreditation; D001771:Blood Banks / Q000458:organization & administration / Q000592:standards / Q000706:statistics & numerical data; D001787:Blood Group Incompatibility / Q000453:epidemiology* / Q000209:etiology; D001788:Blood Grouping and Crossmatching; D001803:Blood Transfusion / Q000706:statistics & numerical data; D004630:Emergencies; D006306:Health Surveys; D006742:Hospital Bed Capacity; D006761:Hospitals / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D007564:Japan / Q000453:epidemiology; D007755:Laboratories, Hospital / Q000458:organization & administration / Q000592:standards / Q000706:statistics & numerical data; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D050316:Medical Order Entry Systems; D008510:Medication Systems, Hospital; D010355:Patient Identification Systems; D065227:Transfusion Reaction
D000017:ABO Blood-Group System