Misinterpretation of blood group and antibody screen leading to serious errors in RhD immunoglobulin administration: A report on first two years of data from Serious Transfusion Incident Reporting program

Christine Akers, Helen Savoia, Stefan Kane, Philip Crispin, Anastazia Keegan, Erica Wood, Bridget Glazebrook, Linley Bielby, Amanda K. Davis

Research output: Contribution to journalArticleResearchpeer-review


The Serious Transfusion Incident Reporting program (STIR) commenced haemovigilance in relation to RhD immunoglobulin (Ig) administration in 2015. During two years of reporting, 21 reports relating to RhD Ig administration were received. Thirty-three percent (7/21) were related to omission of RhD Ig, putting women at risk of RhD alloimmunisation and adverse consequences in future pregnancies. A recent case reported to STIR highlights poor communication and misinterpretation of pathology results leading to significant morbidity from haemolysis in the fetus. STIR makes recommendations related to education of staff and communication between clinical and laboratory staff to improve the safety of patient care.

Original languageEnglish
Pages (from-to)161-164
Number of pages4
JournalAustralian and New Zealand Journal of Obstetrics and Gynaecology
Issue number1
Publication statusPublished - 1 Feb 2019


  • anti-D
  • haemovigilance
  • RhD immunoglobulin

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