A report of 104 transfusion errors in New York State

Authors

  • J.V. Linden MD, MPH,

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  • B. Paul,

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      Bimla Paul, MD, Senior Medical Specialist and Director, Hematology and Blood Services, Bureau of Laboratories, New York City Department of Health, New York, NY; current address: Medical Director, Bio-Reference Laboratory, Elmwood Park, NJ.

  • K.P. Dressler

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      Kenneth P. Dressier, PhD, Assistant Commissioner of Laboratories, Bureau of Laboratories, New York City Department of Health; current address: Director of Technical Services, New York Blood Center, New York, NY.


Director of Blood and Tissue Resources, Wadsworth Center for Laboratories and Research, New York State Department of Health, P. O. Box 509, Empire State Plaza, Albany, NY 12201–0509.

Abstract

In New York State, significant incidents involving the collection, processing, or transfusion of blood must be reported. Incident reports received over a 22-month period involving transfusion of blood to other than the intended recipient or release of blood of an incorrect group were analyzed. Among 1,784,600 transfusions of red cell components; there were 92 cases of erroneous transfusion that met study criteria (1/19,000). There were 54 ABO-incompatible transfusions (1/33,000); three of these (1/600,000) were fatal. Correction for underreporting of ABO-compatible errors resulted in an estimate of 1 per 12,000 as the true risk of transfusion error. National application of New York State data results in an estimate of 800 to 900 projected red cell-associated errors in the United States annually. The majority of reported errors occurred outside of the blood bank (43% resulted solely from failure to identify the patient and/or unit prior to transfusion and 11% resulted from phlebotomist error), while the blood bank was responsible for 25 percent of errors and contributed, with another hospital service, to 17 percent. The risk of transfusion of ABO-incompatible blood remains significant, and additional precautions to minimize the likelihood of such events should be considered.

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