Status:
Ready to upload
Record number:
1259
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Case Report
Time to detection:
1 hour
Alerting signals, symptoms, evidence of occurrence:
A 53-year-old male patient with myelodysplastic syndrome was typed as blood group A Rh(D) positive. He underwent allogeneic transplantation with PBSCs from a sibling donor typed as O Rh(D) negative (i.e. minor ABO incompatibility between the patient and the donor). From Day + 10 his clinical condition began to deteriorate. On Day + 16 two units of PRBCs were requested from the Blood Bank that issued two units of PRBCs with blood type A1 by computer crossmatch. One hour after the transfusion was initiated the patient got chills, moderate temperature elevation, tachycardia and tachypnoea.
Demonstration of imputability or root cause:
Clinical and serologic evidence. Twelve days after transplantation anti-A1 was detected for the first time during routine analyses but unfortunately, further investigation and subsequent electronic blocking of release of blood group A1 PRBC in the blood bank management system was not performed due to a clerical error. Both the pre- and the posttransfusion blood samples were analyzed and revealed that the patient was blood type A2.
Imputability grade:
3 Definite/Certain/Proven
Groups audience:
Keywords:
Suggest new keywords:
anti-A1
Suggest references:
Akkok, C.A., Haugaa, H., Galgerud, A. and Brinch, L. (2013). Severe hemolytic transfusion reaction due to anti-A1 following allogeneic stem cell transplantation with minor ABO incompatibility. Transfus Apher Sci 48(1):63-66.