Unreliable patient identification warrants ABO typing at admission to check existing records before transfusion.
OBJECTIVE
This study describes patient identification errors leading to transfusional near-misses in blood issued by the Alps Mediterranean French Blood Establishment (EFSAM) to Marseille Public Hospitals (APHM) over an 18-month period. The EFSAM consolidates 14 blood banks in southeast France. It supplies 149 hospitals and maintains a centralized database on ABO types used at all area hospitals. As an added precaution against incompatible transfusion, the APHM requires ABO testing at each admission regardless of whether the patient has an ABO record. The study goal was to determine if admission testing was warranted.


METHODS
Discrepancies between ABO type determined by admission testing and records in the centralized database were investigated. The root cause for each discrepancy was classified as specimen collection or patient admission error. Causes of patient admission events were further subclassified as namesake (name similarity) or impersonation (identity fraud).


RESULTS
The incidence of ABO discrepancies was 1:2334 including a 1:3329 incidence of patient admission events. Impersonation was the main cause of identity events accounting for 90.3% of cases. The APHM's ABO control policy prevented 19 incompatible transfusions. In relation to the 48,593 packed red cell units transfused, this would have corresponded to a risk of 1:2526.


CONCLUSIONS
Collecting and storing ABO typing results in a centralized database is an essential public health tool. It allows crosschecking of current test results with past records and avoids redundant testing. However, as patient identification remains unreliable, ABO typing at each admission is still warranted to prevent transfusion errors.
Établissement français du sang Alpes-Méditerranée, 506, avenue du Prado, CS 30002, 13272 Marseille Cx8, France. Electronic address: virginie.ferrera-tourenc@efs.sante.fr.
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Ferrera-Tourenc
Service d'hémovigilance et gestion des risques, hôpital Sainte-Marguerite, Assistance publique-Hôpitaux de Marseille, Pavillon 9, 270, boulevard Sainte-Marguerite, 13274 Marseille Cx9, France.
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Lassale
Établissement français du sang Alpes-Méditerranée, 506, avenue du Prado, CS 30002, 13272 Marseille Cx8, France.
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Chiaroni
Établissement français du sang Alpes-Méditerranée, 506, avenue du Prado, CS 30002, 13272 Marseille Cx8, France.
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Dettori
D001771:Blood Banks; D001787:Blood Group Incompatibility / Q000453:epidemiology / Q000517:prevention & control*; D001788:Blood Grouping and Crossmatching; D001803:Blood Transfusion; D016208:Databases, Factual; D005602:France; D006761:Hospitals; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D010343:Patient Admission; D010355:Patient Identification Systems / Q000379:methods / Q000592:standards*
ABO typing errors; Erreur de typage ABO; Erreur d’identification patient; Erreur transfusionnelle; Impersonation; Patient identification events; Transfusion errors; Usurpation