An incident of incorrect blood component transfusion: The need for constant hemovigilance.

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

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.[23] 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.”