Choi Sooin, Hyun Jungwon, Yu HongBi, Cho Duck
Department of Laboratory Medicine and Genetics, Soonchunhyang University Hospital Bucheon, Soonchunhyang University College of Medicine, Bucheon, Korea.
Department of Laboratory Medicine, Hallym University College of Medicine, Hwaseong, Korea.
Ann Lab Med. 2021 Sep 1;41(5):493-498. doi: 10.3343/alm.2021.41.5.493.
Fatal ABO-incompatible (ABOi) transfusion is one of the most common causes of transfusion-related death, but its reporting has been limited in Korea. We comprehensively reviewed ABOi transfusion events in Korea by analyzing cases reported in literature, Korean hemovigilance system (KOHEVIS) annual reports, and written judgments. Written judgments were assessed using a written judgment management system or a comprehensive legal information system. We found nine cases of ABOi transfusion events in written judgments (from 1953 to 2019), 16 in the KOHEVIS (from 2008 to 2018), and nine in published reports (from 1978 to 2019). One case was found in all three sources. Overall, we found 32 cases of ABOi transfusion events. Four cases died and 23 survived, while the outcomes for five were unavailable. ABOi transfusion errors occurred at the administration (50%, 16/32), sample (13%, 4/32), and testing (9%, 3/32) stages. The causes of errors were unavailable for nine cases (28%, 9/32). We report the status of ABOi transfusions in Korea and expect our results to contribute to the prevention of adverse reactions due to ABOi transfusion.
致命性ABO血型不相容（ABOi）输血是输血相关死亡的最常见原因之一，但在韩国，此类事件的报告一直有限。我们通过分析文献报道的病例、韩国血液警戒系统（KOHEVIS）年度报告以及书面判决，全面回顾了韩国的ABOi输血事件。书面判决通过书面判决管理系统或综合法律信息系统进行评估。我们在书面判决中发现了9例ABOi输血事件（1953年至2019年），在KOHEVIS中发现了16例（2008年至2018年），在已发表报告中发现了9例（1978年至2019年）。在所有三个来源中均发现了1例。总体而言，我们共发现32例ABOi输血事件。4例死亡，23例存活，另有5例结果未知。ABOi输血错误发生在输注阶段的有50%（16/32）、样本阶段有13%（4/32）、检测阶段有9%（3/32）。9例（28%，9/32）错误原因不明。我们报告了韩国ABOi输血的情况，期望我们的结果有助于预防ABOi输血引起的不良反应。
