ABO-Incompatible Transfusion Events Reported in Written Judgments and in the Korean Hemovigilance System

Abstract

Fatal ABO-incompatible (ABOi) transfusion is one of the most common causes of transfusion-related death, but its reporting has been limited in Korea. We comprehensively reviewed ABOi transfusion events in Korea by analyzing cases reported in literature, Korean hemovigilance system (KOHEVIS) annual reports, and written judgments. Written judgments were assessed using a written judgment management system or a comprehensive legal information system. We found nine cases of ABOi transfusion events in written judgments (from 1953 to 2019), 16 in the KOHEVIS (from 2008 to 2018), and nine in published reports (from 1978 to 2019). One case was found in all three sources. Overall, we found 32 cases of ABOi transfusion events. Four cases died and 23 survived, while the outcomes for five were unavailable. ABOi transfusion errors occurred at the administration (50%, 16/32), sample (13%, 4/32), and testing (9%, 3/32) stages. The causes of errors were unavailable for nine cases (28%, 9/32). We report the status of ABOi transfusions in Korea and expect our results to contribute to the prevention of adverse reactions due to ABOi transfusion.

Donor‐type red blood cell transfusion to deplete isoagglutinins prior to allogeneic stem cell transplantation from ABO major incompatible bone marrow donors

“…Erroneous transfusion of ABO major incompatible RBC in unselected clinical settings is typically strongly symptomatic and not infrequently lethal 21–23 . By comparison, controlled transfusion of ABO major incompatible RBCs in our framework of pre‐transplant conditioning was not associated with serious side effects.…”

“…Erroneous transfusion of ABO major incompatible RBC in unselected clinical settings is typically strongly symptomatic and not infrequently lethal. [21][22][23] By comparison, controlled transfusion of ABO major incompatible RBCs in our framework of pre-transplant conditioning was not associated with serious side effects. Thus, 23 patients (44%) showed no or minor attributable reactions (grade 1) during or within 24 h after the transfusion and 26 patients (50%) showed a mild reaction (grade 2) not requiring intervention.…”

Common Data Model-based Analysis of Selective Leukoreduction Protocol Compliance at Three Hospitals

“…NLRRBC transfusion in patients subjected to SLP can be considered for reporting to the hemovigilance system as a prescription error of inappropriate blood components. However, passive surveillance is limited by underreporting [ 6 , 12 ], and NLRRBC transfusion has never been reported as a prescription error in the three institutions involved this study. We adopted CDM analysis to evaluate the success rate of SLP using real-world data.…”

Preventing Blood Transfusion Errors: How Personal Digital Assistants Can Improve Patient Safety

“…The number of near-miss events reported to the transfusion management division during the study period was 0. The discrepancy between the number of near-miss events in the PDA data and the manual reporting system may be attributed to underreporting [6,7]. While near-miss events occur more frequently than actual accidents, it can be challenging to identify them if no system is in place that can detect them at the time of occur- Abbreviations: PDA, personal digital assistant; HO, hematology and oncology; ED, emergency department; ICU, intensive care unit; GW, general ward.…”