The release of unsuitable units through misinterpretation of laboratory results transmitted by facsimile.

BACKGROUND

Preventable errors in transfusion medicine that have a significant risk of adverse outcome include the erroneous administration of blood of the wrong type or blood with unsuitable laboratory test results. Mandatory reports of errors by facilities providing blood services in New York State offer the opportunity for review and analysis of common factors. The state also collects statistics on the collection, laboratory testing, distribution, and disposition of blood in these facilities.

CASE REPORTS

Three serious errors in transfusion medicine occurred within 3 months as a result of the misinterpretation of laboratory test results transmitted by facsimile. Two unsuitable units of blood were erroneously released, and a unit mislabeled as to the ABO group was incorporated into the hospital inventory. One of the unsuitable units was repeatedly reactive for HIV (although negative on confirmatory testing), and the other was confirmed positive for HCV.

CONCLUSIONS

The vast majority of blood collected in New York State is tested by reference laboratories. Results are often transmitted by facsimile. Facsimile results may be misinterpreted because of distortion during transmission, misreading, or failure to note a separate report of pending results. Such misinterpretation results in an increased risk of adverse outcome for transfusion recipients. Laboratory results to be transmitted by facsimile could readily-and should-be clarified.