{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T22:45:18Z","timestamp":1791499518818,"version":"4.3.4"},"reference-count":32,"publisher":"Wiley","issue":"12","license":[{"start":{"date-parts":[[2020,10,16]],"date-time":"2020-10-16T00:00:00Z","timestamp":1602806400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Transfusion"],"published-print":{"date-parts":[[2020,12]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>ABO\u2010incompatible red blood cell (RBC) transfusions and acute hemolytic reactions occur infrequently, yet resultant fatalities are reported to the US Food and Drug Administration (FDA) every year. We describe a 20\u2010year retrospective study of reported mistransfusion cases to identify temporal trends, common causes, and corrective actions taken to prevent recurrence.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Study Design and Methods<\/jats:title>\n                    <jats:p>ABO\u2010incompatible RBC transfusion\u2010related fatalities reported to the FDA in 2000\u20102019 were reviewed for patient demographics, primary attributed cause, contributing factors, and corrective actions.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Eighty reported deaths after ABO\u2010incompatible RBC transfusion occurred in the 20\u2010year period. A decrease in the number of cases after 2008 was sustained through 2019 (mean 6 cases\/y, 2000\u20102009 vs 2 cases\/y, 2010\u20102019). The estimated rate of reported mistransfusion fatalities was 1 per 2 million RBC units transfused in 2000\u20102009 and 1 per 7.14 million RBC units in 2010\u20102019 (\n                      <jats:italic>P<\/jats:italic>\n                      \u2009&lt;\u2009.0001). Administration errors (wrong patient or wrong unit transfused) and sample collection errors (wrong blood in tube [WBIT]) significantly decreased over time but remained the most common causes. In all WBIT cases, verification of patients' ABO type with a second sample or historical type was not performed before transfusion; 16 of 19 (84%) institutions that reported corrective actions subsequently instituted this requirement. In the other categories, 22 of 58 (38%) facilities reported plans for technological process improvements, such as electronic patient identification.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The rate of reported fatalities from ABO\u2010incompatible RBC transfusion has significantly decreased in the past decade. Still, about two cases are reported each year, highlighting gaps in best practices and areas for improvement.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/trf.16121","type":"journal-article","created":{"date-parts":[[2020,10,16]],"date-time":"2020-10-16T13:34:42Z","timestamp":1602855282000},"page":"2867-2875","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":34,"title":["Trend in\n                    <scp>ABO\u2010incompatible RBC<\/scp>\n                    transfusion\u2010related fatalities reported to the\n                    <scp>FDA<\/scp>\n                    , 2000\u20102019"],"prefix":"10.1111","volume":"60","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5316-1006","authenticated-orcid":false,"given":"Emily K.","family":"Storch","sequence":"first","affiliation":[{"name":"Center for Biologics Evaluation and Research U.S. Food and Drug Administration  Silver Spring Maryland USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Beth","family":"Rogerson","sequence":"additional","affiliation":[{"name":"Center for Biologics Evaluation and Research U.S. Food and Drug Administration  Silver Spring Maryland USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anne F.","family":"Eder","sequence":"additional","affiliation":[{"name":"Center for Biologics Evaluation and Research U.S. Food and Drug Administration  Silver Spring Maryland USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2020,10,16]]},"reference":[{"key":"e_1_2_7_2_1","unstructured":"Agency for Healthcare Research and Quality (AHRQ).US Department of Health and Human Services. 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[cited 2020 Sept 2]. Available from:https:\/\/www.fda.gov\/vaccines\u2010blood\u2010biologics\/report\u2010problem\u2010center\u2010biologics\u2010evaluation\u2010research\/transfusiondonation\u2010fatalities."},{"key":"e_1_2_7_13_1","unstructured":"Food and Drug Administration.Notification process for transfusion related fatalities and donation related deaths. [cited 2020 Sept 2]. Available from:https:\/\/www.fda.gov\/vaccines\u2010blood\u2010biologics\/report\u2010problem\u2010center\u2010biologics\u2010evaluation\u2010research\/transfusiondonation\u2010fatalities."},{"key":"e_1_2_7_14_1","unstructured":"Food and Drug Administration.Notifying FDA of fatalities related to blood collection or transfusion. [cited 2020 Sept 2]. Available from:https:\/\/www.fda.gov\/media\/70676\/download."},{"key":"e_1_2_7_15_1","unstructured":"US Department of Health and Human Services.National blood collection and utilization survey. Washington DC. [cited 2020 Sept 2]. Available from:https:\/\/www.hhs.gov\/oidp\/topics\/blood\u2010tissue\u2010safety\/surveys\/national\u2010blood\u2010collection\u2010and\u2010utilization\u2010survey\/index.html."},{"issue":"2","key":"e_1_2_7_16_1","first-page":"S1","article-title":"Slowing decline in blood collection and transfusion in the United States \u2010 2017","volume":"60","author":"Jones JM","year":"2020","journal-title":"Transfusion"},{"key":"e_1_2_7_17_1","doi-asserted-by":"publisher","DOI":"10.1111\/trf.15405"},{"key":"e_1_2_7_18_1","doi-asserted-by":"publisher","DOI":"10.1046\/j.1537-2995.1980.20681057154.x"},{"key":"e_1_2_7_19_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jcjq.2018.08.010"},{"key":"e_1_2_7_20_1","article-title":"ABO Incompatibility reactions among inpatient U.S. medicare beneficiaries ages 65 and older receiving RBC\u2010only transfusions, 2007\u20132019","volume":"60","author":"Menis MWB","year":"2020","journal-title":"Transfusion"},{"key":"e_1_2_7_21_1","volume-title":"The 2017 Annual SHOT Report","author":"Bolton\u2010Maggs PHBE","year":"2018"},{"key":"e_1_2_7_22_1","unstructured":"Serious Hazards of Transfusion (SHOT).Annual Reports and Summaries. 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