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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
Author(s) -
Akers Christine,
Savoia Helen,
Kane Stefan,
Crispin Philip,
Keegan Anastazia,
Wood Erica,
Glazebrook Bridget,
Bielby Linley,
Davis Amanda K.
Publication year - 2019
Publication title -
australian and new zealand journal of obstetrics and gynaecology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.734
H-Index - 65
eISSN - 1479-828X
pISSN - 0004-8666
DOI - 10.1111/ajo.12889
Subject(s) - medicine , antibody , blood transfusion , administration (probate law) , pediatrics , immunology , political science , law
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.