Wrong blood in tube: an occasional lapse or a significant healthcare hazzard
Abstract
Background: Mistakes, while taking, labelling and sending blood samples, are important near miss mistakes in transfusion medicine. These mistakes can potentially lead to a wrong blood transfusion with a fatal outcome and can reflect poorly on the quality of Slovenian healthcare. Because these mistakes are preventable, it is important to identify their causes and to examine possible solutions to prevent potentially fatal complications.
Methods: One of the best quality indicators to identify misidentified samples is quantifying the wrong blood in the tube (WBIT) of all samples sent for blood type and cross-matching. We examined all cases of WBIT recorded at the Blood Transfusion Centre of Slovenia to identify the causes of mistakes and find solutions to this problem.
Results: In the last five years, the number of WBIT ranged between 0.04 and 0.2 promile. In particular, there were nine cases discovered in 2012, two in 2013, six in 2014, five in 2015, eight in 2016 and seven cases in 2017.
Conclusion: The article establishes the percent of WBIT sent to our transfusion centre over the last several years. We have also identified the causes for WBIT along with solutions for resolving this problems within our system. According to the results, we can conclude that in our Blood Transfusion Centre we have low levels of mislabelled/misidentified blood samples and therefore a low risk of mismatched transfusions with a fatal outcome.
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References
Uehlinger J. Educational case: wrong blood in tube. Acad Pathol. 2017;4:1–2. https://doi.org/10.1177/2374289517708310.
Pravilnik o transfuzijskih preiskavah in postopkih ob transfuziji 2007. Ur l RS 9/07.
Allard J, Carthey J, Cope J, Pitt M, Woodward S. Medication errors: causes, prevention and reduction. Br J Haematol. 2002 Feb;116(2):255–65. https://doi.org/10.1046/j.1365-2141.2002.03272.x PMID:11841425
Glavin RJ. Drug errors: consequences, mechanisms, and avoidance. Br J Anaesth. 2010 Jul;105(1):76–82. https://doi.org/10.1093/bja/aeq131 PMID:20507858
Dzik WH, Murphy MF, Andreu G, Heddle N, Hogman C, Kekomaki R, et al.; Biomedical Excellence for Safer Transfusion (BEST) Working Party of the International Society for Blood Transfusion. An international study of the performance of sample collection from patients. Vox Sang. 2003 Jul;85(1):40–7. https://doi.org/10.1046/j.1423-0410.2003.00313.x PMID:12823729
Ansari S, Szallasi A. ‘Wrong blood in tube’: solutions for a persistent problem. Vox Sang. 2011 Apr;100(3):298–302. https://doi.org/10.1111/j.1423-0410.2010.01391.x PMID:20738838
Pownall M. Complex working environment, not poor training, blamed for drug errors. BMJ. 2009;339 dec07 1:b5328. [cited 2018 Jun 10] Available from: http://www.bmj.com/content/339/bmj.b5328https://doi.org/10.1136/bmj.b5328.
Bolton-Maggs PH. SHOT conference report 2016: serious hazards of transfusion - human factors continue to cause most transfusion-related incidents. Transfus Med. 2016 Dec;26(6):401–5. https://doi.org/10.1111/tme.12380 PMID:27995700
Bolton-Maggs PH, Cohen H. Serious Hazards of Transfusion (SHOT) haemovigilance and progress is improving transfusion safety. Br J Haematol. 2013 Nov;163(3):303–14. https://doi.org/10.1111/bjh.12547 PMID:24032719
Varey A, Tinegate H, Robertson J, Watson D, Iqbal A. Factors predisposing to wrong blood in tube incidents: a year’s experience in the North East of England. Transfus Med. 2013 Oct;23(5):321–5. https://doi.org/10.1111/tme.12050 PMID:23808358
Linden JV, Wagner K, Voytovich AE, Sheehan J. Transfusion errors in New York State: an analysis of 10 years’ experience. Transfusion. 2000 Oct;40(10):1207–13. https://doi.org/10.1046/j.1537-2995.2000.40101207.x PMID:11061857
de Mel S, Lim S, Soekojo C, Thow C, Lang SP, Lee SY, et al. Education-based interventions to minimize sampling errors in transfusion. ISBT Sci Ser. 2017;12(2):307–13. https://doi.org/10.1111/voxs.12306.
Hawker C, Messinger BL. Fixing the Problem of Mislabeled Specimens in Clinical Labs. [cited 2018 May 18]. Available from: https://www.aacc.org/publications/cln/articles/2014/april/psf-mislabeled-specimens
Maskens C, Downie H, Wendt A, Lima A, Merkley L, Lin Y, et al. Hospital-based transfusion error tracking from 2005 to 2010: identifying the key errors threatening patient transfusion safety. Transfusion. 2014 Jan;54(1):66–73. https://doi.org/10.1111/trf.12240 PMID:23672511
Thomas W, Davies J, Asamoah A, Scott-Molloy C, Sansom V, Kerr J. Two samples for blood transfusion: single centre experience. Transfus Med. 2014 Aug;24(4):209–12. https://doi.org/10.1111/tme.12122 PMID:24779632
Glisch C, Jawa Z, Brener A, Carpenter E, Gottschall J, Treml A, et al. Evaluation of a two-sample process for prevention of ABO mistransfusions in a high volume academic hospital. BMJ Open Qual. 2018 Jul;7(3):e000270. https://doi.org/10.1136/bmjoq-2017-000270 PMID:30057954
Milkins C, Berryman J, Cantwell C, Elliott C, Haggas R, Jones J, et al.; British Committee for Standards in Haematology. Guidelines for pre-transfusion compatibility procedures in blood transfusion laboratories. Transfus Med. 2013 Feb;23(1):3–35. https://doi.org/10.1111/j.1365-3148.2012.01199.x PMID:23216974
Serious Hazard Working Expert Group (WEG) & Writing Group dbsSSGSG. Annual SHOT report 2011. [cited 2017 Nov 28]. Available from: https://www.shotuk.org/wp-content/uploads/SHOT-ANNUAL-REPORT_FinalWebVersionBookmarked_2012_06_22.pdf
Dzik WH. New technology for transfusion safety. Br J Haematol. 2007 Jan;136(2):181–90. https://doi.org/10.1111/j.1365-2141.2006.06373.x PMID:17092308
MacIvor D, Triulzi DJ, Yazer MH. Enhanced detection of blood bank sample collection errors with a centralized patient database. Transfusion. 2009 Jan;49(1):40–3. https://doi.org/10.1111/j.1537-2995.2008.01923.x PMID:18798804
Delaney M, Dinwiddie S, Nester TN, Aubuchon JA. The immunohematologic and patient safety benefits of a centralized transfusion database. Transfusion. 2013 Apr;53(4):771–6. https://doi.org/10.1111/j.1537-2995.2012.03789.x PMID:22803792
Cottrell S, Watson D, Eyre TA, Brunskill SJ, Dorée C, Murphy MF. Interventions to reduce wrong blood in tube errors in transfusion: a systematic review. Transfus Med Rev. 2013 Oct;27(4):197–205. https://doi.org/10.1016/j.tmrv.2013.08.003 PMID:24075096
Davies A, Staves J, Kay J, Casbard A, Murphy MF. End-to-end electronic control of the hospital transfusion process to increase the safety of blood transfusion: strengths and weaknesses. Transfusion. 2006 Mar;46(3):352–64. https://doi.org/10.1111/j.1537-2995.2006.00729.x PMID:16533276
Bricl I, Marić I. Hemovigilanca – poročilo 2016. Isis. 2017;10:54–9.
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