The preventive effects of a 24-hour system of blood transfusion testing
on mistyping of transfused blood was examined. Blood transfusion tests
have been performed by blood transfusion technologists during working hours
and by physicians at other times. In March 2000, we introduced a system
in which technologists perform blood transfusion tests after working hours.
Technologists of the Blood Transfusion Unit and Central Clinical Laboratory
perform the test jointly, and column agglutination technology was introduced
as the test method. A computer system setup exclusively for the testing
was also introduced to perform computer cross-matching. Since transfusion
error is likely to occur during emergency blood transfusion, a manual was
established to prioritize safety. After introduction of the system, mistyping
that may have been caused by inaccurate blood test results markedly decreased,
confirming the usefulness of this system for prevention of mistyping. In
addition, transfusion errors also decreased in wards and the improved system
increased the safety of the entire medical care system. The frequency of
mistyping was about 1% when physicians performed blood typing, showing
the importance of clinical technologists for blood transfusion tests.
[Rinsho Byori 51 : 50～56, 2003]
*Blood Transfusion Unit, Kansai Medical University Hospital, Moriguchi 570-8507
【Key Words】transfusion error(輸血過誤)，ABO-mismatched transfusion(ABO 不適合輸血)，24-hour system of blood transfusion testing(輸血検査 24 時間体制)，human error(ヒューマンエラー)，emergency transfusion(緊急輸血)
*関西医科大学附属病院輸血部(〒570-8507 守口市文園町10-15)
E-mail :kishimoy@takii.kmu.ac.jp