Description of Event or Problem · 1
ON 09/19/1997 IT WAS REPORTED TO A MEDITECH REPRESENTATIVE THAT A PATIENT SUFFERED A DELAYED SEROLOGICAL TRANSFUSION REACTION TO ANTI-E DUE TO THE LACK OF HISTORICAL BLOOD BANK INFORMATION IN THE NEWLY CONVERTED BLOOD BANK SYSTEM. THE PATIENT INVOLVED HAD BEEN IN THE HOSPITAL IN 07/1997 AND AT THAT TIME, ANTI-E WAS IDENTIFIED AND ENTERED INTO THE OLD DATABASE. ON 09/12/1997, ANOTHER SPECIMEN WAS OBTAINED AND THE ANTIBODY SCREEN PERFORMED ON THIS SPECIMEN WAS NEGATIVE. SINCE THE ANTIBODY SCREEN WAS NEGATIVE AND NO HISTORICAL BLOOD BANK INFORMATION WAS IN THE NEW BLOOD BANK DATABASE, ONLY AN IMMEDIATE SPIN CROSSMATCH WAS PERFORMED ON THE UNITS TO BE TRANSFUSED TO THE PATIENT. THE UNITS WERE LATER TRANSFUSED TO THE PATIENT WITHOUT ANY APPARENT CLINICAL PROBLEMS. ON 09/18/1997, AN ADDITIONAL SPECIMEN WAS OBTAINED IN ORDER TO CROSSMATCH ADDITIONAL UNITS TO THE PATIENT. AN ANTIBODY SCREEN WAS PERFORMED ON THE NEW SPECIMEN AND FOUND TO BE POSITIVE. AT THIS TIME, THE USER FACILITY BECAME AWARE OF THE FACT THAT THE PATIENT HAD SUFFERED A DELAYED SEROLOGICAL TRANSFUSION REACTION. UPON FURTHER INVESTIGATION, THEY DISCOVERED THAT THE TRANSFUSION REACTION WAS DUE TO ANTI-E. THE USER FACILITY REPORTED THAT THEY WERE NOT AWARE OF ANY OTHER OCCURRENCES OF THIS SITUATION WITH OTHER PATIENTS.