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背景 那些可预防的但会带来严重后果的输血医学错误包括错误捷用血型不合或实验室检测不合格的血液。纽约血液机构提供的强制性差错报告的方法能回顾和分析常见的错误原因。该方法中还收集了采血、实验室检测、血液发放、使用等统计表。案例报告:在3个月里发生了3起由于错误理解传真传递的实验室结果引起的严重的输血医学错误。发放了2单位不合格血液,1单位血液在医院记录中ABO血型标签不对。不合格血液中1例为HIV重叠阳性(确证实验为阴性),1例为HCV确证阳性。结论:绝大多数纽约采集的血液均在参比实验室检测,结果通过传真传递。由于传递过程失真、错误阅读、未定结果的单独报告记录失误等因素,传真结果可能会被错误理解。这些错误理解会对受血者造成严重危害。传真传递的实验室结果应简洁明了。
Background Those transfusion medicine errors that are preventable but can have serious consequences include incorrect use of blood with unsuitable blood types or laboratory tests. The method of mandatory error reporting provided by the New York Blood Institute can review and analyze common causes of errors. The method also collects statistics such as blood collection, laboratory tests, blood distribution, and use. Case report: In the 3 months, there were 3 serious transfusion medicine errors due to misinterpretation of the laboratory results of fax transmission. Two units of unqualified blood were issued, and one unit of blood was incorrect in the ABO blood group label in hospital records. One case of unqualified blood was positive for HIV overlap (confirmed by the test was negative), and one case was positive for HCV confirmation. Conclusion: The vast majority of blood collected in New York is tested in the reference laboratory and results are transmitted via fax. Due to factors such as transmission process distortion, misreading, and individual reports of undetermined results, the fax results may be misunderstood. These misunderstandings can cause serious harm to recipients. The laboratory results of the fax transmission should be concise and clear.