Misinterpretation of blood group and antibody screen leading to serious errors in RhD immunoglobulin administration: A report on first two years of data from Serious Transfusion Incident Reporting program

Aust N Z J Obstet Gynaecol. 2019 Feb;59(1):161-164. doi: 10.1111/ajo.12889. Epub 2018 Sep 5.

Abstract

The Serious Transfusion Incident Reporting program (STIR) commenced haemovigilance in relation to RhD immunoglobulin (Ig) administration in 2015. During two years of reporting, 21 reports relating to RhD Ig administration were received. Thirty-three percent (7/21) were related to omission of RhD Ig, putting women at risk of RhD alloimmunisation and adverse consequences in future pregnancies. A recent case reported to STIR highlights poor communication and misinterpretation of pathology results leading to significant morbidity from haemolysis in the fetus. STIR makes recommendations related to education of staff and communication between clinical and laboratory staff to improve the safety of patient care.

Keywords: RhD immunoglobulin; anti-D; haemovigilance.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Australia / epidemiology
  • Blood Group Antigens
  • Blood Transfusion
  • Drug-Related Side Effects and Adverse Reactions / epidemiology*
  • Drug-Related Side Effects and Adverse Reactions / etiology
  • Female
  • Fetomaternal Transfusion / drug therapy
  • Humans
  • Immunoglobulins / administration & dosage
  • Immunoglobulins / adverse effects*
  • Medication Errors*
  • Perinatal Care*
  • Pregnancy
  • Pregnancy Complications, Hematologic / drug therapy
  • Rh Isoimmunization / epidemiology*
  • Rh Isoimmunization / etiology
  • Rh-Hr Blood-Group System*
  • Risk Management

Substances

  • Blood Group Antigens
  • Immunoglobulins
  • Rh-Hr Blood-Group System