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Publication Type: Safety Information
Single or Multiple Incident: Multiple
Date: 6/19/2018 12:00:00 AM
Country: Australia
This alert serves to raise awareness of the potential for error when issuing blood products to a patient of unknown blood group during an emergency. The alert identified that three incidents occurred over the past 20 months of ABO incompatible plasma transfusions during emergency treatment. The alert provides information to ensure the correct blood group is given in an emergency when the blood group is unknown: Patient ABO Group Unknown Red Cells Plasma Products Platelets First Choice O AB A or O Second Choice A (low titre anti-B) Note: Group A Plasma Products may be issued as the second choice due to stock restrictions. These should have a low titre anti-B identified on the label. Recommendations to prevent similar incidents are provided.


Communication
  1. Review Massive Transfusion Protocols (MTP) to ensure that: - Clinical staff are informed that the ABO compatibility for Plasma Products is different to that of red cells.
Rules / Policies / Procedures
  1. Review Massive Transfusion Protocols (MTP) to ensure that: - The LIS rules and control checks are robust enough to ensure that incompatible ABO groups cannot be issued in error.
  2. Review Massive Transfusion Protocols (MTP) to ensure that: • One clinician has primary responsibility for liaison with the laboratory during an MTP or emergency.
  3. Review Massive Transfusion Protocols (MTP) to ensure that: Blood products issued in an emergency from the Laboratory are issued via the LIS prior to release as a checking process.
  4. Review Massive Transfusion Protocols (MTP) to ensure that: - An alternative safety check should be considered where there is a manual sign out process in an emergency from a satellite location.

ABO Compatibility for Blood Products in an Emergency