Makroo Raj Nath, Bhatia Aakanksha
Department of Transfusion Medicine, Molecular Biology and Transplant Immunology, Indraprastha Apollo Hospitals, New Delhi, India.
Asian J Transfus Sci. 2017 Jan-Jun;11(1):18-21. doi: 10.4103/0973-6247.200783.
Blood grouping is the single most important test performed by each and every transfusion service. A blood group error has a potential for causing severe life-threatening complications. A number of process strategies have been adopted at various institutions to prevent the occurrence of errors at the time of phlebotomy, pretransfusion testing, and blood administration. A delta check is one such quality control tool that involves the comparison of laboratory test results with results obtained on previous samples from the same patient.
We retrieved the records of all transfusion-related incidents reported in our institute, between January 2008 and December 2014. Errors identified as "Failed Delta checks" and their root cause analyses (RCA) were reviewed.
A total of 17,034 errors related to blood transfusion were reported. Of these, 38 were blood grouping errors. Seventeen blood group errors were identified due to failed delta checks, where the results of two individually drawn grouping samples yielded different blood group results. The RCA revealed that all of these errors occurred in the preanalytical phase of testing. Mislabeling resulting in wrong blood in tube was the most commonly identified cause, accounting for 11 of these errors, while problems with correct patient identification accounted for 5 failed delta checks.
Delta checks proved to be an effective tool for detecting blood group errors and prevention of accidental mismatched blood transfusions. Preanalytical errors in patient identification or sample labeling were the most frequent.
血型鉴定是每个输血服务机构进行的最重要的单项检测。血型错误有可能引发严重的危及生命的并发症。各机构已采用多种流程策略来预防在静脉采血、输血前检测及输血过程中出现错误。差值核对就是这样一种质量控制工具，它涉及将实验室检测结果与同一患者先前样本的检测结果进行比较。
我们检索了2008年1月至2014年12月期间我院报告的所有输血相关事件的记录。对被认定为“差值核对失败”的错误及其根本原因分析（RCA）进行了审查。
共报告了17034例与输血相关的错误。其中，38例为血型鉴定错误。因差值核对失败而确定的17例血型错误中，两次单独采集的血型样本结果显示不同的血型。根本原因分析表明，所有这些错误均发生在检测的分析前阶段。导致试管内血液错误的贴错标签是最常见的原因，在这些错误中占11例，而正确识别患者方面的问题导致5例差值核对失败。
差值核对被证明是检测血型错误和预防意外血型不匹配输血的有效工具。患者识别或样本标签方面的分析前错误最为常见。
