Analysis of wrong blood in tube events at a hospital-based blood centre in a tertiary care referral hospital: A perspective from a lower middle-income country

BACKGROUND AND OBJECTIVES

Wrong blood in tube (WBIT) continues to be a preventable cause of unintended harm to the patient. The literature describing extent of the problem, its consequences and factors leading to WBIT from the perspective of lower middle-income countries (LMICs) is limited. The present study describes WBIT and its outcome in a hospital-based blood centre from an LMIC.

MATERIALS AND METHODS

WBIT events occurring during the study period were analysed to identify the root cause. In addition, they were analysed according to discipline, department and time of sample draw. Root causes were divided and compared with standard operating procedure (SOP) for sample collection for blood requests. All WBIT events were followed and their outcomes analysed.

RESULTS

WBIT events occurred at a rate of 4.8/10,000 blood requests, with a higher rate in urgent requests (5.2/10,000 requests). The average rate of WBIT was higher in surgical disciplines compared to medical and acute care services (6.58 vs. 4.43 vs. 3/10,000 requests). The highest rate of WBIT was observed when requests were received during 8:00 PM-2:00 AM (p = 0.02). Deviations from SOP with contribution from human and organizational elements were identified as the root cause. The consequences ranged from delay in providing blood to acute haemolytic transfusion reactions.

CONCLUSION

We found that WBITs occurred at a rate comparable to that reported from developed countries. Use of software and automation may reduce the rate of WBIT but not eliminate it completely. Strict adherence to SOPs and continuous training of phlebotomy staff would help reduce it to a minimum. Blood centres need to develop specific strategies with respect to their root causes.

Blood sampling - Two sides to the story

This study aimed to investigate why there is variability in taking blood. A multi method Pilot study was completed in four National Health Service Scotland hospitals. Human Factors/Ergonomics principles were applied to analyse data from 50 observations, 15 interviews and 12-months of incident data from all Scottish hospitals. The Functional Resonance Analysis Method (FRAM) was used to understand why variability may influence blood sampling functions. The analysis of the 61 pre blood transfusion sampling incidents highlighted limitations in the data collected to understand factors influencing performance. FRAM highlighted how variability in the sequence of blood sampling functions and the number of practitioners involved in a single blood sampling activity was influenced by the working environment, equipment, clinical context, work demands and staff resources. This pilot study proposes a realistic view of why blood sampling activities vary and proposes the need to consider the system's resilience in future safety management strategies.

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

'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.

Interventions to reduce wrong blood in tube errors in transfusion: a systematic review

This systematic review addresses the issue of wrong blood in tube (WBIT). The objective was to identify interventions that have been implemented and the effectiveness of these interventions to reduce WBIT incidence in red blood cell transfusion. Eligible articles were identified through a comprehensive search of The Cochrane Library, MEDLINE, EMBASE, Cinahl, BNID, and the Transfusion Evidence Library to April 2013. Initial search criteria were wide including primary intervention or observational studies, case reports, expert opinion, and guidelines. There was no restriction by study type, language, or status. Publications before 1995, reviews or reports of a secondary nature, studies of sampling errors outwith transfusion, and articles involving animals were excluded. The primary outcome was a reduction in errors. Study characteristics, outcomes measured, and methodological quality were extracted by 2 authors independently. The principal method of analysis was descriptive. A total of 12,703 references were initially identified. Preliminary secondary screening by 2 reviewers reduced articles for detailed screening to 128 articles. Eleven articles were eventually identified as eligible, resulting in 9 independent studies being included in the review. The overall finding was that all the identified interventions reduced WBIT incidence. Five studies measured the effect of a single intervention, for example, changes to blood sample labeling, weekly feedback, handwritten transfusion requests, and an electronic transfusion system. Four studies reported multiple interventions including education, second check of ID at sampling, and confirmatory sampling. It was not clear which intervention was the most effective. Sustainability of the effectiveness of interventions was also unclear. Targeted interventions, either single or multiple, can lead to a reduction in WBIT; but the sustainability of effectiveness is uncertain. Data on the pre- and postimplementation of interventions need to be collected in future trials to demonstrate effectiveness, and comparative studies are needed of different interventions.