Adding Automation and Independent Dual Verification to Reduce Wrong Blood in Tube (WBIT) Events

Abstract

Objectives Transfusions remain a complicated procedure involving many disciplines performing various steps. Pretransfusion specimen identification errors remain a concern. Over the past two decades, system changes have been made and minimal improvements in the error rates have been seen. Wrong blood in tube (WBIT) events may lead to mistransfusions of components with life-threatening complications. Methods A continuous quality improvement effort involving the introduction of electronic patient identification at the point of pretransfusion specimen collection (an automated system improvement), manual independent dual verification, and periodic education (human process system improvements) were implemented. Results Both automated and human system process improvements resulted in greater than 10-fold reduction in WBIT events and a 47% reduction in mislabeled specimens. Conclusions Diligent improvement and implementation of combination automated system processes and human protocols with continuous monitoring led to great reductions in WBIT error rates and labeling discrepancies, leading to an increase in system safety. These combinations of improvement can lead to more decreased error rates if applied to other critical process steps in the transfusion process.

Informing the State of Process Modeling and Automation of Blood Banking and Transfusion Services Through a Systematic Mapping Study

“…This has been achieved by automating the entry and inquiry of electronic test orders, reading the identity of patients from their wristbands, verifying the matching of patient identity with the prescribed blood product, and calculating the number of ordered units. 26 , 30 , 36 The last BB&T process that has been automated is the administrative process that includes tracking, workflow management, control of workstation quality, and real-time monitoring. 26 , 36 …”

How do we ensure a safe ABO recheck process?

“…Moreover, combinations of these approaches may act synergistically to mitigate error rates. 7 Regardless of the mitigation strategy or strategies employed, several other considerations are worth mentioning.…”

“…The aforementioned WBIT mitigation strategies are not an exhaustive list; many other approaches exist (Table 2). Moreover, combinations of these approaches may act synergistically to mitigate error rates 7 . Regardless of the mitigation strategy or strategies employed, several other considerations are worth mentioning.…”

“…Such errors can happen in a variety of ways and for various reasons (Table 1) and are divided almost evenly between a wrong label being applied to an intended recipient's tube and a wrong patient's blood drawn in a tube labeled for the intended patient 3 . Published WBIT rates are highly variable, ranging from roughly one in every 1000–10,000 specimens received in the TM laboratory 3–8 . Though there has been an overall decrease in fatal ABO hemolytic transfusion reactions over the past 15 years, 8,9 fatalities still occur annually in the United States due to mistransfusion 9…”

“…3 Published WBIT rates are highly variable, ranging from roughly one in every 1000-10,000 specimens received in the TM laboratory. [3][4][5][6][7][8] Though there has been an overall decrease in fatal ABO hemolytic transfusion reactions over the past 15 years, 8,9 fatalities still occur annually in the United States due to mistransfusion. 9 Regulations exist to prevent WBITs and the risk of ABO-incompatible transfusions.…”