Asian Journal of Transfusion Science
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LETTER TO THE EDITOR Table of Contents   
Year : 2015  |  Volume : 9  |  Issue : 2  |  Page : 216
An incident of incorrect blood component transfusion: The need for constant hemovigilance


1 Department of Transfusion Medicine, Maharishi Markandeshwar University, Ambala, Mullana, India
2 Department of Transfusion Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India

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Date of Web Publication12-Aug-2015
 

How to cite this article:
Malhotra S, Dhawan HK, Sharma RR, Marwaha N. An incident of incorrect blood component transfusion: The need for constant hemovigilance. Asian J Transfus Sci 2015;9:216

How to cite this URL:
Malhotra S, Dhawan HK, Sharma RR, Marwaha N. An incident of incorrect blood component transfusion: The need for constant hemovigilance. Asian J Transfus Sci [serial online] 2015 [cited 2022 Jan 23];9:216. Available from: https://www.ajts.org/text.asp?2015/9/2/216/162731


Sir,

An incident is when "a patient receives a blood component that did not meet all the requirements for a suitable transfusion for that patient or was intended for another patient." [1] Here, we report a case of incorrect blood component transfusion of single donor apheresis platelet unit (SDAP) which fortunately did not result in adverse reaction.

A requisition for SDAP unit without accompanying patient's sample and for a packed red blood cell (PRBC) unit with patient's sample was received in the apheresis and cross-match section, respectively, for a 46-year-old male with a diagnosis of acute myeloid leukemia [Figure 1]. The blood group of the patient mentioned on both the requisition forms was B positive. Hence, a B positive SDAP unit was bled and transfused without any adverse event. However, in the cross-match section, the blood group came out to be AB positive. The blood group was re-confirmed as AB positive from repeat sample; two AB positive PRBC units were cross-matched and transfused to the patient after B positive SDAP transfusion.
Figure 1: Serial hematologic parameters of the patient

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On scrutiny of previous records, it was noted that 3 days ago, a similar request for SDAP and PRBC was received for this patient. The blood group of the patient mentioned on the SDAP request form was B positive; thus B positive SDAP was transfused. Blood group was not written on the PRBC requisition form. The blood group was tested to be AB positive, and one AB positive PRBC was cross-matched but not issued, hence the discrepancy could not be highlighted at that time. Despite two ABO incompatible SDAP transfusions, direct antiglobulin test was negative, and posttransfusion platelet count showed an adequate rise.

No adverse event was seen in the present case despite the transfusion of two ABO incompatible SDAPs (B group donor plasma to AB group recipient). Our patient was a 46-year-old diabetic male (weighing 90 kg) on immunosuppressive therapy. Due to the large blood volume of the patient, anti-A antibody in 200-300 mL of B group SDAP would be too diluted to cause any hemolytic reaction. Second, antibodies in plasma are neutralized by binding to soluble blood group substances. The same unit if transfused to a pediatric patient could result in life-threatening transfusion reaction. [2],[3] Anti-A antibody titers in both donors were low (1:16).

Concluding, it may be emphasized that the present case constitutes a nonevent incident where transfusion of a wrong SDAP unit did not result in any adverse reaction. However, the reported incident led to a constructive response such that it was made mandatory for patient's blood group to be confirmed from the fresh sample for an SDAP requisition received in the apheresis section. A Department of Transfusion Medicine (DTM) serial number is issued for every patient, and the same DTM number is recorded on all subsequent SDAP requisitions.

Reporting of such events is necessary as the use of such information and the corrective measures subsequently deployed enhance the safety of the transfusion process, increasing our ability to "get it right."

 
   References Top

1.
Stainsby D, Faber JC, Jorgensen J. Overview of hemovigilance. In: Toby S, Snyder EL, Solheim BG, Stowell CP, Strauss BG, Petrides M, editors. Rossi's Principles of Transfusion Medicine. 4 th ed. West Sussex: Blackwell Publishing Ltd.; 2009. p. 683-98.  Back to cited text no. 1
    
2.
Berséus O, Boman K, Nessen SC, Westerberg LA. Risks of hemolysis due to anti-A and anti-B caused by the transfusion of blood or blood components containing ABO-incompatible plasma. Transfusion 2013;53 Suppl 1:114S-23.  Back to cited text no. 2
    
3.
Larsson LG, Welsh VJ, Ladd DJ. Acute intravascular hemolysis secondaryto out-of-group platelet transfusion. Transfusion 2000;40:902-6.  Back to cited text no. 3
    

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Correspondence Address:
Dr. Sheetal Malhotra
Department of Transfusion Medicine, Maharishi Markandeshwar University, Ambala, Mullana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-6247.162731

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2006 - Asian Journal of Transfusion Science | Published by Wolters Kluwer - Medknow
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