case report of a systematic error in blood transfusion

ABSTRACT

Hemolytic transfusion reactions have been one of the most common causes of transfusion related mortalities and morbidities. Increased vigilance and use of newer technologies could lead in decreased rate of complications. A 19-year-old man with a broken leg, under anesthesia and surgery, received 2 packs of RBCs. Afterwards, he admitted in the intensive care unit of the hospital for supportive care. Later assessments revealed that the transfused blood, confirmed by the hospital blood bank, had not been really isogroup. Transfusion related medical errors are still inducting a considerable rate of mortality and morbidity in our health system. Systematic approaches [including enhancement of the role of hospital transfusion committees] to lower these complications could lead in decreased rate of errors