Infrequently, laboratory antibody identification techniques may fail to detect clinically significant antibodies, resulting in an incompatible blood transfusion. 9,000 apheresis platelet preparations derived from group O donors have been associated with acute intravascular hemolysis. Of note, the increasing popularity of apheresis platelets may contribute to such reactions. Apheresis products often are transfused to patients with a minor ABO compatibility mismatch. Verbal and stat orders Simultaneous specimen processing from more than one patient Manual issuance of blood Overriding computer error messages Insufficient segregation of units in refrigerators Product Deviation Investigation.
Human error is inevitable.
Careful investigation of deviations is necessary to identify process weaknesses and reduce the potential for future error. Identification of the root cause of the deviation is critical in all investigations. For example, determining that a phlebotomist incorrectly labeled a patient's hospital admission blood sample explains how ABO mismatched blood was erroneously transfused during surgery, but serves little to prevent future incidents. The root cause of the mislabeling must be identified. Many transfusion deviations occur as a result of multiple factors.