Failure of bedside ABO testing is still the most common cause of incorrect blood transfusion in the Barcode era

Transfus Apher Sci. 2005 Aug;33(1):25-9. doi: 10.1016/j.transci.2005.04.006.


Background and objectives: ABO-incompatible red blood cell (RBC) transfusions are a major risk in transfusion medicine. Identification of factors leading to this hazard is important to improve transfusion safety.

Material and methods: All consecutive erroneous ABO-incompatible transfusions occurring from January 1997 to December 2004 at the Charité University Hospital in Berlin, Germany were analysed.

Results: A total of 343,432 RBC units were transfused, and eight patients erroneously received 13 ABO-incompatible RBC concentrates. The most frequent error was incorrect bedside testing (n=7). Intensive care treatment was required in two cases, but there were no fatal mistransfusions. Four patients had no or only mild reactions.

Conclusion: Mistransfusions are still a considerable risk in transfusion medicine despite quality control systems and electronic data processing. An increase in transfusion safety may require the introduction of further systems, e.g. radio-frequency identification (RFID) tags.

MeSH terms

  • ABO Blood-Group System* / analysis
  • Aged
  • Blood Group Incompatibility*
  • Blood Grouping and Crossmatching*
  • Electronic Data Processing
  • Erythrocyte Transfusion*
  • Female
  • Humans
  • Male
  • Medical Errors
  • Middle Aged
  • Point-of-Care Systems
  • Risk Factors


  • ABO Blood-Group System