Blood or not in the obstetric setting? When should you transfuse?

Abstract

Introduction: Blood transfusion in obstetrics and gynaecology accounts for 3.8% of red cells transfused in Victoria and 5% in SA according to the Bloodhound project undertaken by the Blood Service. Wrong blood in tube errors occur regularly, 11% of transfusion errors in one study, and can result in an incorrect blood group being recorded. In obstetrics this can lead to inappropriate or missed Anti-D administration for pregnant women, as well as the potential for an ABO incompatible transfusion. The Blood Matters program in Victoria collects transfusion related adverse events, including wrong blood in tube errors (WBIT), via the Serious Transfusion Incident Reporting program (STIR). These data have been collected since 2006. During this time 1473 reports received (to 31/12/14), of which 28% (419/1473) are WBIT reports. Of these 419 reports 30% occur in the maternity or delivery suite, and often involve cord blood specimens. There are specific issues in relation to collection of these specimens that increase the chance of errors occurring. Aim: To make clear the risks of wrong blood in tube errors (WBIT), where the specimen and request are labelled for one patient, but the blood in the tube actually belongs to a different patient and how these errors can be avoided to increase patient safety. This poster will report on several cases studies from STIR that highlight where problems occur, and methods health services are employing to address these problems. Implications: The transfusion chain involves many steps. One of the earliest steps is specimen collection for blood grouping and/or cross-matching. Errors at this point in the chain can have catastrophic results if they lead to incorrect or incompatible transfusion. Knowledge of how WBITs occur will assist staff in avoiding these errors and improve patient safety.