TY - JOUR JF - Blood-Journal JO - Sci J Iran Blood Transfus Organ VL - 2 IS - 5 PY - 2005 Y1 - 2005/9/01 TI - A case report of a systematic error in blood transfusion TT - گزارش یک مورد خطای سیستماتیک در تجویز خون N2 -   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 SP - 197 EP - 201 AU - Malek, B. AU - Vosoughian, M. AU - Esfahani, F. AU - Dabbagh, A. AU - Rajaeei, S. AD - KW - Hemolytic KW - Transfusion reaction KW - Blood transfusion KW - Medical error UR - http://bloodjournal.ir/article-1-45-en.html ER -