Wrong blood in tube: an occasional lapse or a significant healthcare hazzard
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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