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Consecutive national surveys of ABO-incompatible blood transfusion in Japan. 2009

Y Fujii, and Y Shibata, and S Miyata, and S Inaba, and T Asai, and Y Hoshi, and J Takamatsu, and K Takahashi, and H Ohto, and T Juji, and K Sagawa
Department of Blood Transfusion, Yamaguchi University Hospital, Yamaguchi, Japan. yfujii-ygc@umin.ac.jp

OBJECTIVE Morbidity and mortality from ABO-incompatible transfusion persist as consequences of human error. Even so, insufficient attention has been given to improving transfusion safety within the hospital. METHODS National surveys of ABO-incompatible blood transfusions were conducted by the Japanese Society of Blood Transfusion, with support from the Ministry of Health, Labor and Welfare. Surveys concluded in 2000 and 2005 analysed ABO-incompatible transfusion data from the previous 5 years (January 1995 to December 1999 and January 2000 to December 2004, respectively). The first survey targeted 777 hospitals and the second, 1355 hospitals. Data were collected through anonymous questionnaires. RESULTS The first survey achieved a 77.4% response rate (578 of 777 hospitals). The second survey collected data from 251 more hospitals, but with a lower response rate (61.2%, or 829 of 1355 hospitals). The first survey analysed 166 incidents from 578 hospitals, vs. 60 incidents from 829 hospitals in the second survey. The main cause of ABO-incompatible transfusion was identification error between patient and blood product: 55% (91 of 166) in the first survey and 45% (27 of 60) in the second. Patient outcomes included nine preventable deaths from 1995 to 1999, and eight preventable deaths from 2000 to 2004. CONCLUSIONS Misidentification at the bedside persists as the main cause of ABO-incompatible transfusion.

UI MeSH Term Description Entries
D007564 Japan A country in eastern Asia, island chain between the North Pacific Ocean and the Sea of Japan, east of the Korean Peninsula. The capital is Tokyo. Bonin Islands
D007755 Laboratories, Hospital Hospital facilities equipped to carry out investigative procedures. Hospital Laboratories,Hospital Laboratory,Laboratory, Hospital
D008510 Medication Systems, Hospital Overall systems, traditional or automated, to provide medication to patients in hospitals. Elements of the system are: handling the physician's order, transcription of the order by nurse and/or pharmacist, filling the medication order, transfer to the nursing unit, and administration to the patient. Hospital Drug Distribution Systems,Hospital Medication System,Hospital Medication Systems,Medication System, Hospital,Drug Distribution System, Hospital,Drug Distribution Systems, Hospital,Hospital Unit Dose Drug Distribution System,Hospital Unit Dose Drug Distribution Systems,System Hospital Medication,Systems, Medication Hospital,Hospital Medication, System,Hospital Medications, System,Hospital System, Medication,Hospital Systems, Medication,Medication Hospital System,Medication Hospital Systems,Medication, System Hospital,Medications, System Hospital,System Hospital Medications,System, Hospital Medication,System, Medication Hospital,Systems, Hospital Medication
D010355 Patient Identification Systems Organized procedures for establishing patient identity, including use of bracelets, etc. Patient Tracking,Identification System, Patient,Identification Systems, Patient,Patient Identification System,Patient Trackings,System, Patient Identification,Systems, Patient Identification,Tracking, Patient,Trackings, Patient
D001771 Blood Banks Centers for collecting, characterizing and storing blood or plasma. Bank, Blood,Banks, Blood,Blood Bank
D001787 Blood Group Incompatibility An antigenic mismatch between donor and recipient blood. Antibodies present in the recipient's serum may be directed against antigens in the donor product. Such a mismatch may result in a transfusion reaction in which, for example, donor blood is hemolyzed. (From Saunders Dictionary & Encyclopedia of Laboratory Medicine and Technology, 1984). ABO Compatibility,ABO Incompatibility,Blood Group ABO Incompatibility,Blood Type Incompatibility,Rh Compatibility,Rh Incompatibility,ABO Compatibilities,ABO Incompatibilities,Blood Group Incompatibilities,Blood Type Incompatibilities,Compatibility, ABO,Compatibility, Rh,Incompatibilities, Blood Group,Incompatibility, ABO,Incompatibility, Blood Group,Incompatibility, Blood Type,Incompatibility, Rh,Rh Compatibilities,Rh Incompatibilities
D001788 Blood Grouping and Crossmatching Testing erythrocytes to determine presence or absence of blood-group antigens, testing of serum to determine the presence or absence of antibodies to these antigens, and selecting biocompatible blood by crossmatching samples from the donor against samples from the recipient. Crossmatching is performed prior to transfusion. Blood Typing,Crossmatching, Blood,Blood Grouping,Blood Crossmatching,Grouping, Blood,Typing, Blood
D001803 Blood Transfusion The introduction of whole blood or blood component directly into the blood stream. (Dorland, 27th ed) Blood Transfusions,Transfusion, Blood,Transfusions, Blood
D004630 Emergencies Situations or conditions requiring immediate intervention to avoid serious adverse results. Emergency
D006306 Health Surveys A systematic collection of factual data pertaining to health and disease in a human population within a given geographic area. Abortion Surveys,Abortion Survey,Health Survey,Survey, Abortion,Survey, Health,Surveys, Abortion,Surveys, Health

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