AU - Malek, B. AU - Vosoughian, M. AU - Esfahani, F. AU - Dabbagh, A. AU - Rajaeei, S. TI - A case report of a systematic error in blood transfusion PT - JOURNAL ARTICLE TA - Blood-Journal JN - Blood-Journal VO - 2 VI - 5 IP - 5 4099 - http://bloodjournal.ir/article-1-45-en.html 4100 - http://bloodjournal.ir/article-1-45-en.pdf SO - Blood-Journal 5 AB  -   Abstract    Background and Objectives  Hemolytic transfusion reactions have been one of the most common causes of transfusion related mortalities and morbidities. Increased vigilance and use of newer technologies could lead in decreased rate of complications.     Case   A 19-year-old man with a broken leg, under anesthesia and surgery, received 2 packs of RBCs. Afterwards, he was admitted in the intensive care unit of the hospital for supportive care. Later assessments revealed that the transfused blood, though confirmed by the hospital blood bank, had not been really isogroup.    Conclusions  Transfusion related medical errors are still inducing a considerable rate of mortality and morbidity in our health system. Systematic approachesn (including enhancement of the role of hospital transfusion committees) to lower these complications could lead in decreased rate of errors.     Key words: Hemolytic, Transfusion reaction, Blood transfusion, Medical error CP - IRAN IN - LG - eng PB - Blood-Journal PG - 197 PT - Research YR - 2005