Record number:
1144
Adverse Occurrence type:
MPHO Type:
Alerting signals, symptoms, evidence of occurrence:
When put from liquid nitrogen into vapor phase at the Cord blood Bank, the 1st bag of the CBU broke up. The 2nd bag also lost its cap and had to be destroyed. The work-up of this unit had to be canceled. A new transplant was planned for this patient.
Demonstration of imputability or root cause:
Discovered on transfer
Suggest references:
World Marrow Donor Association.S(P)EAR Committee Annual Report - year 2012