[Improving blood safety: errors management in transfusion medicine].

INTRODUCTION: The concept of blood safety includes the entire transfusion chain starting with the collection of blood from the blood donor, and ending with blood transfusion to the patient. The concept involves quality management system as the systematic monitoring of adverse reactions and incidents regarding the blood donor or patient. Monitoring of near-miss errors show the critical points in the working process and increase transfusion safety. OBJECTIVE: The aim of the study was to present the analysis results of adverse and unexpected events in transfusion practice with a potential risk to the health of blood donors and patients. METHODS: One-year retrospective study was based on the collection, analysis and interpretation of written reports on medical errors in the Blood Transfusion Institute of Vojvodina. RESULTS: Errors were distributed according to the type, frequency and part of the working process where they occurred. Possible causes and corrective actions were described for each error. The study showed that there were not errors with potential health consequences for the blood donor/patient. Errors with potentially damaging consequences for patients were detected throughout the entire transfusion chain. Most of the errors were identified in the preanalytical phase. The human factor was responsible for the largest number of errors. CONCLUSION: Error reporting system has an important role in the error management and the reduction of transfusion-related risk of adverse events and incidents. The ongoing analysis reveals the strengths and weaknesses of the entire process and indicates the necessary changes. Errors in transfusion medicine can be avoided in a large percentage and prevention is cost-effective, systematic and applicable.

[Immunized pregnant woman with rare Rh fenotype--case report].

INTRODUCTION: Rh blood group system is one of the most polymorphic systems of human blood and consists of 50 antigens. Antigen D is the most important antigen in the Rh system and next to ABO, is the most clinically significant in transfusion medicine. The aim of this paper was to present a case of a rare Rh phenotype ccDEE in an immunized pregnant woman, whose fourth pregnancy ended with birth of a female newborn infant with hemolytic disease of the lower level. CASE REPORT: The history of a 42-year-old pregnant woman stated that she had had four pregnancies. She was transfused with 1500 ml of whole blood, three units of packed red cells and two units of fresh frozen plasma. Due to her high-risk pregnancy she was referred to the Clinic of Gynecology and Obstetrics in Novi Sad. Blood sample was tested in the Department of Prenatal Care of the Institute for Blood Transfusion Vojvodina. ABO and Rh were tested, antibody screening was done by indirect antiglobulin test and the detected antibodies were identified by gel technology. The results of testing were: O RhD positive, Rh phenotype ccDEE, positive screening for red blood cells antibodies by indirect antiglobulin test, alo anti-e antibody. According to the literature data, it is a very rare Rh phenotype whose incidence in the population ranges from 0.34% to 1.99%. The compatible blood products for the patient and her newborn were searched for on the basis of the immunoserology tests. CONCLUSION: Two major problems within transfusion medicine have emerged in our case: the problem of immunization of pregnant woman with a rare blood type and the problem of finding compatible blood. Health care of pregnant women can be improved by following pregnancies according to the national antenatal testing algorithm and better teamwork of gynecologists and transfusions.

[Transfusion management of patients with red blood cell antibodies]. / Transfuziolosko zbrinjavanje bolesnika sa eritrocitnim antitelima.

INTRODUCTION: Red blood cell antibodies may cause a positive result of pre-transfusion blood compatibility testing (crossmatch test). It can be a problem to provide suitable blood units for patients with clinically significant antibodies to high-frequency antigens as well as for those with multiple alloantibody specificities. This study was aimed at identifying transfused patients in the population of South-Backa who had developed clinically significant red blood cell alloantibodies. MATERIAL AND METHODS: We analyzed the records of crossmatch results and antibody screening performed at the Blood Transfusion Institute of Vojvodina during 2012. RESULTS: Antibodies were found in 103 patients: A) 63 patients with single antibodies: 1) 16 with antibodies of unknown specificity (3 autoantibodies, 13 alloantibodies); 2) 39 with clinically significant antibodies (23 from Rh system (2 anti-C, 2 anti-D, 12 anti-E, 7 anti-c), 4 anti-K, 3 anti-Fya, 7 anti-Jka, 2 anti-S); 3) 8 with usually not significant antibodies (6 anti-M, 1 anti-Al, 1 antiC); B) 40 patients developed multiple antibodies: 1) all patients had at least one clinically significant antibody from various blood group system (44 Rh, 13 Kell, 7 Kidd, 7 MNSs (S, s)); 2) 3 patients had usually not significant antibodies (1 Lewis, 2 Lutheran); 3) 3 patients occasionally had clinically significant antibody (3 anti-Ytd4) 3 patients had antibodies of unknown specificity (2 autoantibodies, lalloantibody). Antibodies detected in the majority of patients (65-63.1%) had a specificity of Rh and/or the Kell system. CONCLUSIONS: The main goal of pre-transfusion blood compatibility testing is to detect clinically significant antibodies. The provision of antigen negative blood units for those patients is a special challenge for blood establishments. Database with a sufficient number of typed blood donors can help to resolve this problem.