Errors reported in cross match laboratory: a prospective data analysis.
BACKGROUND
Human errors contribute to one half of all ABO-incompatible transfusions and transfusion-associated fatalities.


METHODS
We report distribution, type and frequency of errors through a prospective study designed specifically to determine errors reported in the cross match lab with their clinical outcome, and to investigate the contributing factors, and underlying system problems.


RESULTS
A total of 342 errors (6.2 per 1000 samples) were reported with majority of the errors being clerical (87.1%) and occurred outside the blood bank (86.5%). Labelling errors were the most frequent incidents encountered with bedside being the major site of deviation. The rate of labeling errors was 6.4 errors per 1000 samples (0.64%) in 32,189 samples studied. Among 80,100 components transfused, the frequency of incorrect blood component transfusion (IBCT) was estimated to be 22.5/100,000 blood components transfused. Miscollected samples (WBIT) occurred at a rate of 1 in 1532 samples (0.65 per 1000 samples). More than half of these errors occurred during the day shift (9 errors per 1000 request form) but more with urgent demands (11 errors per 1000 request form).


CONCLUSIONS
This study indicates the importance of proper specimen labeling and implemented cost-effective, non-compromising policy of rejecting each mislabelled specimen and realises the importance of ongoing quality monitoring to improve laboratory performance.
Centre for Transfusion Medicine (Blood Services Group), Health Sciences Authority, Singapore 169078, Singapore.
Rashmi
R
Tondon
Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raibarely Road, Lucknow, UP 226014, India.
Prashant
P
Pandey
Centre for Transfusion Medicine (Blood Services Group), Health Sciences Authority, Singapore 169078, Singapore.
Koh Boon Chai
KBC
Mickey
Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raibarely Road, Lucknow, UP 226014, India. Electronic address: rkcchaud@sgpgi.ac.in.
Rajendra
R
Chaudhary
D000017:ABO Blood-Group System; D001787:Blood Group Incompatibility / Q000150:complications / Q000401:mortality; D001803:Blood Transfusion / Q000401:mortality; D006801:Humans; D007753:Laboratories; D019300:Medical Errors / Q000191:economics / Q000517:prevention & control / Q000706:statistics & numerical data*; D057766:Policy; D011356:Product Labeling; D011446:Prospective Studies; D011786:Quality Control; D013048:Specimen Handling / Q000379:methods; D065227:Transfusion Reaction
D000017:ABO Blood-Group System