Wrong blood in tube – potential for serious outcomes: can it be prevented?

Abstract

Summary ‘Wrong blood in tube’ (WBIT) errors, where the blood in the tube is not that of the patient identified on the label, may lead to catastrophic outcomes, such as death from ABO‐incompatible red cell transfusion. Transfusion is a multistep, multidisciplinary process in which the human error rate has remained unchanged despite multiple interventions (education, training, competency testing and guidelines). The most effective interventions are probably the introduction of end‐to‐end electronic systems and a group‐check sample for patients about to receive their first transfusion, but neither of these eradicates all errors. Further longer term studies are required with assessment before and after introduction of the intervention. Although most focus has been on WBIT in relation to blood transfusion, all pathology samples should be identified and linked to the correct patient with the same degree of care. Human factors education and training could help to increase awareness of human vulnerability to error, particularly in the medical setting where there are many risk factors.

Evaluating the knowledge and practices of nurses and paramedics in blood transfusion services – A survey in the states of Tamil Nadu and Pondicherry, India

“…[8] The outstanding finding every year from Serious Hazards of Transfusion UK confidential hemovigilance reporting is that incorrect blood component transfusions make up the largest group of adverse incidents and are the most serious of these are ABO-incompatible red cell transfusions resulting in death or major morbidity. [9] Most are due to clerical error\which occurs at bedside while collecting blood sample from the patient or misidentification of blood sample at the blood bank. Porras et al .…”

“…[18] Bolton-Maggs and Cohen in her review states errors still occur even after training and competency-assessment of Healthcare professionals as there is a human factor involved. [19] The concept of just-culture has to be introduced in blood transfusion services which emphasize that errors result from system based issues and not human failure.…”

Administration Safety of Blood Products - Lessons Learned from a National Registry for Transfusion and Hemotherapy Practice

“…Special IT-based safety features are proposed to erase user errors, e.g., the use of bar codes [19] and radiofrequency identification (RFID) tracking systems [20][21][22] from blood sampling to transfusion [23]. Using a computerized administration guide, the documentation of drug and blood administration can be improved.…”

Pre‐ and postanalytical errors in haematology

“…The magnitude of these errors in terms of best use of healthcare resources and potential for patient harm is applicable in all laboratory medicine specialties. The authors would support, however, an approach to specimen identification and labelling similar to that used to resolve “wrong blood in tube” incidents in blood transfusion …”