Abstract
ABO-incompatible transfusion due to human error is the most important cause of adverse events during transfusion. The National Survey on the present status of ABO-incompatible blood transfusions in Japan was conducted by the Japanese Society of Blood Transfusion. The survey targeted 1,355 hospitals. Data were collected by an anonymous questionnaire-based survey. Reports of ABO-incompatible transfusion in the 5-year period between January 2000 and December 2004 were analyzed. Target blood products included whole blood, red cell concentrates and fresh-frozen plasma (FFP) and platelet concentrates (PC). Among the 1,355 hospitals surveyed, responses were obtained from 829 (61.2%). Sixty cases of ABO-incompatible transfusion were reported, involving major mismatch of red cell concentrates in 22 cases, minor mismatch of red cell concentrates in 9, FFP in 19, PC in 8 and unknown products in 2. The main causes of transfusion error were identification error between patient and blood product in 27 (45%), phlebotomy error in 2 (3%), prescription error in 8 (13%), testing error by doctors in 10 (17%), laboratory error by technicians in 10 (17%) and other error in 3 (5%). Outcomes in patients transfused with ABO-incompatible blood were recorded as deceased in 8, in 4 of whom the cause of death could nevertheless not be distinguished as due to the ABO-incompatible transfusion or the underlying disease. Incorrect blood recipient identification at the patient's bedside remains the main cause of ABO-incompatible transfusion.
