Errors in patient specimen collection: application of statistical process control

Abstract

A simple SPC method is described that can monitor the process of sample collection and labeling in any hospital. SPC could be applied to other critical steps in the transfusion processes as a tool for biovigilance and could be used to develop regional or national performance standards for pretransfusion sample collection. A link is provided to download the spreadsheet for free.

Unreliable patient identification warrants ABO typing at admission to check existing records before transfusion

“…In relation to the 48,593 RBC units transfused, the risk of error would have been 1:2526. In agreement with Dzik et al and Murphy et al [4,11], our findings indicate that cross-checking current blood group results with stored records provides a second line of defense not only against sample error but also against identity error.…”

“…Labelling requirements include stringent specimen acceptance criteria at the blood bank and cross-checking current and previous patient grouping results [3][4][5]. Process failure rates estimated by recording mislabelled and miscollected samples range from 6.1 to 13.0:1000 [6,7] and 0.35 to 0.5:1000 [6][7][8][9] respectively.…”

Error reporting in transfusion medicine at a tertiary care centre: a patient safety initiative

“…Similar to our fi ndings, samples with labeling errors, failure to check patient identity at the bedside and remote labeling of samples in areas such as the nursing station have been demonstrated to have a strong correlation with WBIT errors (7) . There are several methods that have been suggested to reduce WBIT errors in literature: ongoing monitoring and analysis of labeling and collection (24) , formulation of national standards of performance for sample collection from patients (20) and use of statistical process control (SPC) techniques for monitoring process over time and to alert responsible parties when a process wanders out of control (25) . Inappropriate storage of components at the site of use (wards or Operation Theaters) was a major error found in this study (20 % of all reported events).…”

A benchmarking program to reduce red blood cell outdating: implementation, evaluation, and a conceptual framework

“…This website allowed hospitals to access bubble plots that could be used to compare their RBC outdating rates with the rates of other hospitals of similar size, geographic location, and transfusion activity . Each hospital also had access to their trends in RBC outdating over time, using statistical process control charts . Training webinars ran from February to June 2010, and a user instruction manual was provided to participants.…”