Unit Placement Errors: A Potential Risk Factor for ABO and Rh Incompatible Blood Transfusions

Abstract

Policy at our institution requires the hospital whole blood and packed RBC inventory (approximately 400 units) to be stored in an orderly arrangement without crowding, with units of the same ABO/Rh grouped together and each group of units clearly segregated from the others. In spite of this policy, over a 38-month period, 112 of 96,581 units (0.12%) were placed into the inventory incorrectly (so called unit placement errors). Thirty-seven of these unit placement errors (0.04%) could have resulted in ABO incompatible crossmatches or transfusions, and an additional 20 errors (0.02%) could have resulted in Rh incompatible transfusions. These data demonstrated the need for our laboratory personnel to routinely perform a systematic check of the blood inventory to detect incorrectly located units and to carefully check the group and type on each unit at the time of its selection. Although these data were collected at a large and busy transfusion service laboratory, they may be representative of what occurs at small as well as at other large facilities. It might be prudent for hospital transfusion services to have a policy that both minimizes the occurrence of unit placement errors and allows for their routine detection, should they occur.