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P.A.C.E. Continuing Education · Transfusion Medicine

TRANSFUSION SURPRISES...THE ONES YOU NEVER EXPECT

Allan Dubon, MLS

MONDAY

58,000/µL

THE ONE THAT ALMOST GOT AWAY.

Allan, professional headshot taken during his leukemia treatment

THE ONE THAT ALMOST GOT AWAY.

MINE.

THE WEEK

  1. MONDAY

    WBC 58,000 /µL

  2. TUESDAY

    Cancer specialist

  3. THURSDAY

    Admitted to Huntsman Cancer Institute

    WBC in the 70,000s /µL

“That one almost got away.”

MARCH 11, 2020

Allan holding a Happy Birthday sign while connected to chemotherapy infusions in the hospital

BONE MARROW / FLOW CYTOMETRY

MARCH 11, 2020

Interpretation

Flow cytometry
~69% atypical B-lineage lymphoblasts
Immunophenotype
CD19+ · CD34+ · TdT+ · HLA-DR+

Consistent with B lymphoblastic leukemia/lymphoma

WHAT AM I MISSING?

GO WITH WHAT YOU KNOW.

— Michelle Dubon

GO WITH WHAT YOU KNOW.

— Michelle Dubon

When something doesn't fit,

go back to the last thing you KNOW is correct.

THIS HOUR

INVESTIGATE

  • Unexpected pretransfusion results

EVALUATE

  • Safety when process, urgency and people collide

CHALLENGE

  • How evidence applies to the patient in front of us

HDFN / RhIG

“SHE REFUSED THE RhIG.”

CASE BACKGROUND

MOTHER

  • RhD-negative
  • Multiple pregnancies
  • RhIG had been declined

SEROLOGY

  • Maternal anti-D developed

INFANT

  • Significant hemolytic disease of the fetus/newborn
  • Required exchange transfusion

WORK BACKWARD

  1. EXCHANGE TRANSFUSION
  2. ↑HDFN
  3. ↑MATERNAL IgG ANTI-D
  4. ↑RhD ALLOIMMUNIZATION
  5. ↑EXPOSURE TO RhD-POSITIVE FETAL RBCs
  6. ↑PREVENTION OPPORTUNITY

WHAT THIS ESTABLISHES

SENSITIZATION

  • RhD-negative individuals can become alloimmunized following exposure to RhD-positive RBCs.

TRANSFER

  • Maternal IgG anti-D can cross the placenta and cause hemolysis of fetal/neonatal RhD-positive RBCs.

PREVENTION

  • RhIG is used to prevent RhD alloimmunization in appropriate unsensitized RhD-negative patients.
  • RhIG does not erase an established immune anti-D.

SUB-NOTE — SOURCE: Use of Rh Immune Globulin and Considerations in the Setting of Supply Shortages and Limited Availability AABB · Association Bulletin #24-02. 2024.

RhD ALLOIMMUNIZATION

~16%
→
<0.1%

Historical risk compared with appropriate RhIG prophylaxis.

SUB-NOTE — SOURCE: Use of Rh Immune Globulin and Considerations in the Setting of Supply Shortages and Limited Availability AABB · Association Bulletin #24-02. 2024.

ROUTINE DOESN'T MEAN UNIMPORTANT.

SEROLOGIC SURPRISES

WOULD YOU STOP HERE?

These are not exam questions. They are exercises in knowing when an investigation is complete.

CASE 1

ANTIBODY SCREEN

Cell I
2+
Cell II
0
Cell III
2+
Autocontrol
0

Screen positive. Autocontrol negative.

CASE 1

SELECTED PANEL CELLS

CellEcKFyᵃJkᵃAHG
1++0+02+
20++0+0
3++00+2+
40+0++0
5+++++2+
60+0000

CASE 1

SELECTED PANEL CELLS

CellEcKFyᵃJkᵃAHG
1++0+02+
20++0+0
3++00+2+
40+0++0
5+++++2+
60+0000

Reactivity tracks with E.

WOULD YOU STOP HERE?

CASE 1 · ANTI-E

KNOW / THINK / NEED

KNOW

  • Every reactive selected cell is E positive.
  • Every nonreactive selected cell is E negative.
  • Autocontrol negative.

THINK

  • Likely anti-E.

NEED

  • Patient phenotype and transfusion history considerations.
  • Appropriate exclusion of additional clinically significant antibodies.

PREMATURE CLOSURE

CASE 2 · KIDD

SELECTED CELLS

CellJkᵃ phenotypeAHG
1Jk(a+b−)2+
2Jk(a+b+)0
3Jk(a+b−)2+
4Jk(a−b+)0
5Jk(a+b+)w+
6Jk(a−b+)0

Stronger reactions with homozygous antigen expression.

Weak or nonreactive heterozygous cells.

WHAT DO YOU NOTICE?

HISTORY

anti-Jkᵃ identified 4 years earlier

HISTORY

anti-Jkᵃ identified 4 years earlier

GO WITH WHAT YOU KNOW.

“Sometimes the most important result in today's workup was performed four years ago.”

THE HISTORY ALMOST GOT AWAY.

CASE 3 · WARM AUTOANTIBODY

EVERYTHING IS INCOMPATIBLE.

Screen
3+ / 3+ / 3+
Panel
Panreactive
Autocontrol
3+
Crossmatches
Incompatible

WHAT DO YOU WANT NEXT?

CASE 3 · WARM AUTOANTIBODY

DAT

IgG
Positive
C3
Negative

WARM AUTOANTIBODY? ARE WE DONE?

CASE 3 · WARM AUTOANTIBODY

KNOW / THINK / NEED

KNOW

  • Panreactivity with a positive autocontrol and a DAT positive for IgG.

THINK

  • Findings compatible with a warm autoantibody.

NEED

Warm autoantibodies can mask clinically significant underlying alloantibodies.

Depending on history, urgency, testing capability, phenotype/genotype and facility processes, additional investigation may be necessary.

Possible tools: phenotype/genotype · adsorption · eluate · reference laboratory investigation.

SUB-NOTE — SOURCE: Johnson ST et al. Evaluating patients with autoimmune hemolytic anemia in the transfusion service and immunohematology reference laboratory: pretransfusion testing challenges and best transfusion-management strategies Hematology Am Soc Hematol Educ Program. 2022;2022(1):96–104. 2022. doi:10.1182/hematology.2022000406

“LEAST INCOMPATIBLE”

IS THAT ACTUALLY WHAT WE'RE LOOKING FOR?

SUB-NOTE — SOURCE: Johnson ST et al. Evaluating patients with autoimmune hemolytic anemia in the transfusion service and immunohematology reference laboratory: pretransfusion testing challenges and best transfusion-management strategies Hematology Am Soc Hematol Educ Program. 2022;2022(1):96–104. 2022. doi:10.1182/hematology.2022000406

FOCUS INSTEAD ON

  1. Excluding clinically significant alloantibodies
  2. ↓Phenotype / genotype information
  3. ↓Appropriate antigen matching
  4. ↓Urgency
  5. ↓Communication

“The way I learned to say this isn't necessarily the way we should say it today.”

SUB-NOTE — SOURCE: Johnson ST et al. Evaluating patients with autoimmune hemolytic anemia in the transfusion service and immunohematology reference laboratory: pretransfusion testing challenges and best transfusion-management strategies Hematology Am Soc Hematol Educ Program. 2022;2022(1):96–104. 2022. doi:10.1182/hematology.2022000406

WHAT ALMOST GOT AWAY?

ANTI-E

What almost got away?

  • PREMATURE CLOSURE

KIDD

What almost got away?

  • HISTORY + DOSAGE

WARM AUTO

What almost got away?

  • POSSIBLE UNDERLYING ALLOANTIBODY

WHAT AM I MISSING?

GO WITH WHAT YOU KNOW.

2:13 AM

MASSIVE TRANSFUSION PROTOCOL ACTIVATED

PROCESS SURPRISES

Level I trauma · Active hemorrhage · No completed type and screen · Reliable history unavailable

WHAT HAPPENS FIRST?

  • AWait until pretransfusion testing is complete before issuing RBCs.
  • BInitiate the facility’s emergency-release/MTP process while compatibility testing continues concurrently.
  • CWait for historical ABO confirmation before issuing blood.
  • DIssue the closest available product and reconcile testing/documentation afterward.

PROCESS SURPRISES

Level I trauma · Active hemorrhage · No completed type and screen · Reliable history unavailable

WHAT HAPPENS FIRST?

  • AWait until pretransfusion testing is complete before issuing RBCs.
  • BInitiate the facility’s emergency-release/MTP process while compatibility testing continues concurrently.
  • CWait for historical ABO confirmation before issuing blood.
  • DIssue the closest available product and reconcile testing/documentation afterward.

B. Initiate the facility’s emergency-release/MTP process while compatibility testing continues concurrently.

EMERGENCY RELEASE IS A PROCESS.

NOT THE ABSENCE OF ONE.

SPEED DOESN'T REPLACE PROCESS.

GOOD PROCESS CREATES SAFE SPEED.

PATIENT IS BLEEDING

simultaneously

CLINICAL TEAM

  • Resuscitation
  • Hemorrhage control
  • MTP communication

TRANSFUSION SERVICE

  • Emergency product release
  • Patient identification
  • Specimen acquisition / testing
  • Inventory management
  • Compatibility testing continues

COMMUNICATION

  • What has been issued?
  • What testing is complete?
  • What isn't complete?
  • When can product selection change?

“THE PATIENT IS GOING TO DIE, AND IT'S GOING TO BE YOUR FAULT.”

THEY WERE LOOKING AT A DYING HUMAN BEING.

I WAS LOOKING AT IDENTITY, COMPATIBILITY, TESTING, AND AVAILABLE PRODUCTS.

THE SAFEST ANSWER REQUIRED BOTH OF US.

UNLABELED SPECIMEN

WHOSE BLOOD IS THIS?

Once an unlabeled specimen leaves the patient's side, the laboratory cannot scientifically reconstruct patient identity from the blood inside it.

THE RESULT CAN BE PERFECTLY ACCURATE

AND STILL BELONG TO THE WRONG PATIENT.

“IT'S JUST AN ARMBAND.”

At my former facility, a dedicated blood-bank identification band was part of the transfusion identification process.

IDENTITY ISN'T ADMINISTRATIVE.

IT IS PART OF COMPATIBILITY.

THE TWO SIDES OF HURRY

CLINICAL TEAM HEARS

“The blood bank is delaying blood.”

BLOOD BANK HEARS

“Skip the safety steps.”

BOTH SIDES NEED A DIFFERENT QUESTION.

WHAT CAN SAFELY HAPPEN RIGHT NOW?

What still needs to happen next?

PROCESS

MTP

  • THE CLOCK

SPECIMEN

  • IDENTITY

COMMUNICATION

  • PERSPECTIVE

NONE OF THESE ARE ANTIBODIES.

ALL OF THEM CAN HURT A PATIENT.

A 2026 NEWS REPORT

PARENTS CLAIM 3-MONTH-OLD GOT WRONG BLOOD TRANSFUSION AT HOSPITAL

WLBT / Gray Media / WXIX · August 6, 2026

SUB-NOTE — SOURCE: Brooklyn Andres · WXIX/Gray News via WLBT. et al. Parents claim 3-month-old got wrong blood transfusion at hospital WLBT. 2026.

“By the time staff intervened, the Gilberts say Emmie had already received 12 milliliters of O-negative blood. She should have received Kell-positive blood, according to the parents.”

WLBT / GRAY MEDIA / WXIX · AUGUST 6, 2026

SUB-NOTE — SOURCE: Brooklyn Andres · WXIX/Gray News via WLBT. et al. Parents claim 3-month-old got wrong blood transfusion at hospital WLBT. 2026.

“By the time staff intervened, the Gilberts say Emmie had already received 12 milliliters of O-negative blood. She should have received Kell-positive blood, according to the parents.”

WLBT / GRAY MEDIA / WXIX · AUGUST 6, 2026

WHAT’S WRONG WITH THIS STORY?

SUB-NOTE — SOURCE: Brooklyn Andres · WXIX/Gray News via WLBT. et al. Parents claim 3-month-old got wrong blood transfusion at hospital WLBT. 2026.

WHAT WE WERE TOLD

THE REPORT

  • Infant in the NICU
  • O-negative RBCs reportedly administered
  • Approximately 12 mL reportedly transfused
  • Blood reportedly described as “unscreened”

THE CLAIMS

  • Transfusion reportedly stopped because it was “not compatible”
  • “She should have received Kell-positive blood”

SUB-NOTE — SOURCE: Brooklyn Andres · WXIX/Gray News via WLBT. et al. Parents claim 3-month-old got wrong blood transfusion at hospital WLBT. 2026.

DO WE ACTUALLY KNOW WHAT HAPPENED?

WHAT WE DON’T KNOW

CLINICAL CONTEXT

  • Maternal antibody history
  • Infant ABO/Rh type
  • DAT result
  • Antibody identification
  • Donor unit K antigen status
  • Whether hemolysis was demonstrated

PROCESS AND LANGUAGE

  • What “unscreened” meant
  • What “not compatible” meant
  • Why the transfusion was stopped
  • Whether emergency-release procedures were involved
  • Whether “Kell-positive” was reported incorrectly or misunderstood

WE DO NOT HAVE ENOUGH INFORMATION.

SUB-NOTE — SOURCE: Brooklyn Andres · WXIX/Gray News via WLBT. et al. Parents claim 3-month-old got wrong blood transfusion at hospital WLBT. 2026.

WHAT WE DO KNOW

O NEGATIVE ≠ K NEGATIVE

O-negative tells us: ABO group O · RhD-negative

It does NOT tell us the donor unit’s K antigen status.

MAYBE THERE WAS ANTI-K.

MAYBE SOMEBODY MEANT K-NEGATIVE.

MAYBE “UNSCREENED” MEANT ANTIGEN STATUS HAD NOT BEEN CONFIRMED.

MAYBE IT WAS EMERGENCY RELEASE.

MAYBE IS NOT DATA.

KEEP THE CATEGORIES SEPARATE

REPORTED

  • What the story says

ESTABLISHED

  • What the science supports

ASSUMED

  • What we supplied ourselves

When a story does not make sense, do not repair the missing clinical story in your own head.

  1. WHAT DO I KNOW?
  2. ↓WHAT AM I ASSUMING?
  3. ↓WHAT WOULD I NEED TO KNOW NEXT?

GO WITH WHAT YOU KNOW.

WHAT IF THE THING THAT DOESN'T FIT...

IS THE EVIDENCE?

THE EVIDENCE BEHIND THE NEXT TWENTY MINUTES

HEMODYNAMICALLY STABLE ADULT

8.4g/dL

TRANSFUSE?

2023 AABB RBC GUIDELINE

<7g/dL

For most hemodynamically stable hospitalized adults, the guideline recommends a restrictive transfusion strategy, considering RBC transfusion when hemoglobin is below 7 g/dL.

AT 8.4 g/dL:

THE GUIDELINE THRESHOLD ALONE WOULD NOT INDICATE RBC TRANSFUSION.

SUB-NOTE — SOURCE: Carson JL et al. Red Blood Cell Transfusion: 2023 AABB International Guidelines JAMA. 2023. doi:10.1001/jama.2023.12914 Co-author: Allan Dubon, MLS.

ACUTE MYOCARDIAL INFARCTION

8.4g/dL

NOW?

The number did not change. Only the clinical context changed.

2025 AABB AMI GUIDELINE

<10g/dL

For hospitalized patients with acute myocardial infarction, the panel suggests a liberal RBC transfusion strategy when hemoglobin is below 10 g/dL.

Conditional recommendation · Low-certainty evidence

AT 8.4 g/dL:

THIS PATIENT FALLS WITHIN THE RANGE WHERE THE AMI GUIDELINE SUGGESTS A LIBERAL TRANSFUSION STRATEGY.

SUB-NOTE — SOURCE: Pagano MB et al. Red Cell Transfusion in Acute Myocardial Infarction: AABB International Clinical Practice Guidelines Annals of Internal Medicine. 2025. doi:10.7326/ANNALS-25-00706 Co-author: Allan Dubon, MLS.

SAME VALUE · DIFFERENT POPULATION

HEMODYNAMICALLY STABLE HOSPITALIZED ADULT

Hb 8.4 g/dL

  • General 2023 RBC guideline
  • Consider transfusion at:
  • <7 g/dL

ACUTE MYOCARDIAL INFARCTION

Hb 8.4 g/dL

  • 2025 AMI guideline
  • Suggest liberal strategy at:
  • <10 g/dL
  • Conditional · Low-certainty evidence

SAME HEMOGLOBIN.

DIFFERENT CLINICAL CONTEXT.

SUB-NOTE — SOURCE: Carson JL et al. Red Blood Cell Transfusion: 2023 AABB International Guidelines JAMA. 2023. doi:10.1001/jama.2023.12914 Co-author: Allan Dubon, MLS.

SUB-NOTE — SOURCE: Pagano MB et al. Red Cell Transfusion in Acute Myocardial Infarction: AABB International Clinical Practice Guidelines Annals of Internal Medicine. 2025. doi:10.7326/ANNALS-25-00706 Co-author: Allan Dubon, MLS.

8.4g/dL

THE NUMBER DIDN'T CHANGE.

THE PATIENT DID.

SUB-NOTE — SOURCE: Carson JL et al. Red Blood Cell Transfusion: 2023 AABB International Guidelines JAMA. 2023. doi:10.1001/jama.2023.12914 Co-author: Allan Dubon, MLS.

SUB-NOTE — SOURCE: Pagano MB et al. Red Cell Transfusion in Acute Myocardial Infarction: AABB International Clinical Practice Guidelines Annals of Internal Medicine. 2025. doi:10.7326/ANNALS-25-00706 Co-author: Allan Dubon, MLS.

FOR WHOM?

IN WHAT CLINICAL CONTEXT?

BASED ON WHAT EVIDENCE?

GUIDELINE PROCESS

  1. DATA
  2. ↓CERTAINTY
  3. ↓BENEFITS vs HARMS
  4. ↓PATIENT VALUES
  5. ↓FEASIBILITY / RESOURCES
  6. ↓RECOMMENDATION

EVIDENCE DOESN’T INTERPRET ITSELF.

A RECOMMENDATION IS NOT JUST A NUMBER.

The 2023 recommendation was built for general hospitalized adults. The 2025 recommendation was built for patients with acute myocardial infarction — a different population, a different body of evidence, and a different certainty.

THE NUMBER IS DATA.

THE CONTEXT GIVES IT MEANING.

GO WITH WHAT YOU KNOW.

Know the population.

Know the recommendation.

Know the certainty.

Know the patient in front of you.

THE SAME REASONING, AGAIN

DATA / INTERPRETATION / RECOMMENDATION

DATA

  • Earlier: panel reactions.
  • Now: clinical evidence.

INTERPRETATION

  • Earlier: likely antibody.
  • Now: certainty, benefits and harms.

RECOMMENDATION

  • Earlier: what to transfuse.
  • Now: what to recommend, and how strongly.

Scientists distinguish observation from interpretation.

PLATELETS · SCHEDULED FOR LUMBAR PUNCTURE

18,000/µL

TRANSFUSE?

2025 AABB / ICTMG GUIDELINE

<20× 10³/µL

Lumbar puncture

Strong recommendation

High/moderate-certainty evidence

AT 18,000 /µL:

YES — THE GUIDELINE RECOMMENDS PROPHYLACTIC PLATELET TRANSFUSION.

SUB-NOTE — SOURCE: Metcalf RA et al. Platelet Transfusion: 2025 AABB and ICTMG International Clinical Practice Guidelines JAMA. 2025. doi:10.1001/jama.2025.7529 Co-author: Allan Dubon, MLS.

SAME PATIENT · SAME PROCEDURE

22,000/µL

NOW?

SAME PATIENT · SAME PROCEDURE

22,000/µL

THE GUIDELINE THRESHOLD ALONE WOULD NOT INDICATE PROPHYLACTIC TRANSFUSION.

BUT THAT IS NOT THE REAL LESSON.

THE REAL QUESTION IS NOT:

“WHAT IS THE PLATELET THRESHOLD?”

SUB-NOTE — SOURCE: Metcalf RA et al. Platelet Transfusion: 2025 AABB and ICTMG International Clinical Practice Guidelines JAMA. 2025. doi:10.1001/jama.2025.7529 Co-author: Allan Dubon, MLS.

2025 AABB / ICTMG GUIDELINE

THE CLINICAL SITUATION CHANGES THE RECOMMENDATION.

NONBLEEDING CHEMOTHERAPY / ALLOGENEIC STEM CELL TRANSPLANT

<10 × 10³/µL

Strong recommendation

CENTRAL VENOUS CATHETER — COMPRESSIBLE SITE

<10 × 10³/µL

Conditional recommendation

LUMBAR PUNCTURE

<20 × 10³/µL

Strong recommendation

HIGH RISK INTERVENTIONAL RADIOLOGY

<50 × 10³/µL

Conditional recommendation

MAJOR NONNEURAXIAL SURGERY

<50 × 10³/µL

Conditional recommendation

SUB-NOTE — SOURCE: Metcalf RA et al. Platelet Transfusion: 2025 AABB and ICTMG International Clinical Practice Guidelines JAMA. 2025. doi:10.1001/jama.2025.7529 Co-author: Allan Dubon, MLS.

SO WHAT'S THE PLATELET THRESHOLD?

THRESHOLD FOR WHOM?

DOING WHAT?

AND WHY?

THE NUMBER IS A TOOL.

THE PATIENT PROVIDES THE CONTEXT.

GO WITH WHAT YOU KNOW.

Know the recommendation.

Know the procedure.

Know the patient.

Know what the evidence actually applies to.

THE SAME QUESTION ALL DAY

ANTIBODY PANEL

  • What am I missing?

EMERGENCY RELEASE

  • What can safely happen now?

NEWS STORY

  • What do I actually know?

GUIDELINE

  • Who is the patient?

DON'T LET THE FIRST ANSWER END THE INVESTIGATION.

DO I KNOW ENOUGH YET?

PERSONAL CLOSING

THE PATIENT BEHIND THE TUBE

“I'd spent my career understanding transfusion as a laboratorian. Then I became the patient.”

Allan's brother smiling while holding a baby outdoors

A LIFE IN TWO FRAMES

MY BROTHER.

Allan's brother in a hospital bed preparing for stem cell donation with Allan beside him

A LIFE IN TWO FRAMES

MY DONOR.

I wouldn’t be standing here without him.

THE TUBE ISN'T THE PATIENT.

THE NUMBER ISN'T THE PATIENT.

THE GUIDELINE ISN'T THE PATIENT.

They're tools we use to take care of one.

MONDAY

58,000/µL

WHAT IF SHE HAD ONLY ORDERED THE H&H?

WHAT AM I MISSING?

GO WITH WHAT YOU KNOW.

— Michelle Dubon

GO WITH WHAT YOU KNOW.

— Michelle Dubon

When something doesn't fit,

go back to the last thing you KNOW is correct.

THE BEST BLOOD BANKERS AREN'T THE PEOPLE

WHO NEVER GET SURPRISED.

THEY'RE THE PEOPLE WHO KNOW WHAT TO DO

WHEN THEY ARE.

WHAT ALMOST GOT AWAY FROM YOU?

A result that didn't fit.

A history that changed everything.

A process that failed.

A case you still remember.