Record number:
1146
Adverse Occurrence type:
MPHO Type:
Alerting signals, symptoms, evidence of occurrence:
Transplant center physician selected this CBU based on 10/10 match with HLA-C report from confirmatory typing. That information had been entered incorrectly at cooperative registry. Product was infused before repeat typing at TC was completed showing that original registry report had been correct. Recipient engrafted.
Demonstration of imputability or root cause:
Cooperative registry identity of HLA-C was correct in registry, but was entered incorrectly with confirmatory typing. TC physician selected this unit based on confirmatory result at C.
Imputability grade:
3 Definite/Certain/Proven
Keywords:
Suggest references:
World Marrow Donor Association.S(P)EAR Committee Annual Report - year 2012