To err is human nature. Can transfusion errors due to human factors ever be eliminated?

Background: Fatal hemolytic transfusion reaction due to ABO incompatibility occurs mainly as a result of clerical errors. Blood sample drawn from the wrong patient and labeled as another patient's specimen will not be detecte d by the blood bank unless there is a previous ABO grouping result. Methods : In Hong Kong, we had designed a transfusion wristband system-portable bar code scanner system to detect such clerical errors. The system was well acc epted by the house staff and had prevented two BO mismatched transfusion. O ther current system of patient's identification may have similar results, b ut the wristband system has the advantages of being simple, inexpensive and easy to implement. The Hong Kong Government is planning to replace the per sonal identity card for all citizens with an electronic smart card by 2003. If the new card contains the person's detailed red cell phenotypes in digi tal code, then the phenotypes of all blood donors and admitted patients wil l be readily available. It is feasible to issue phenotype-matched blood to patients without any need of pre-transfusion testing, therefore eliminating mismatched transfusions for most patients. Results: Our pilot study of 474 patients showed that the system was safe and up to 98% of admitted patient s could be transfused without delays. Conclusions: Patients with rare pheno types, visitors or illegal immigrants may still need pre-transfusion antibo dy screen, but if most patients can be issued blood units without testings, the potential savings in health care amount to US$14 million/year. (C) 200 1 Elsevier Science B.V. All rights reserved.