Transfusions - Case study A

Patient given anti-D unnecessarily: This woman required an elective Caesarean section and a blood sample was taken for grouping…

Patient given anti-D unnecessarily: This woman required an elective Caesarean section and a blood sample was taken for grouping and screening before surgery.

The patient's chart had been left out for the doctor, who thought she was O Rh D negative but did not confirm this by checking the patient's notes.

Anti-D was given despite the patient stating that her blood group was Rh D positive.

The error was discovered when the doctor who had prescribed and administered the product went to the medical notes to record the administration and discovered the patient's group to be O Rh D positive.

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The patient was exposed unnecessarily to a blood product. There were no guidelines at this hospital; anti-D was not issued by the laboratory for individual patients but was stored in the ward fridge for use by clinical staff.