Enhanced detection of blood bank sample collection errors with a centralized patient database

Pittsburgh's Centralized Transfusion Service (CTS) provides transfusion support to 16 hospitals and features an electronic database that contains patient transfusion and serologic histories. This database can be accessed from any hospital in the system. A major cause of ABO-incompatible transfusions is the "wrong blood in tube" (WBIT) phenomenon, that is, the sample is not from the recipient identified on the label. We hypothesized that having access to patient historical ABO types from anywhere in the CTS system can identify WBIT errors and prevent mistransfusions.

The transfusion committee records of the 16 CTS hospitals from March 2005 to September 2007 were reviewed for major collection errors, that is, the current ABO type differed from the historical type in the database. The patient's historical ABO type, the discrepant type, and the hospital(s) where these samples were collected were recorded.

In 6 of 16 major collection errors for which complete information was available, the current and historical ABO types were obtained from different hospitals within the CTS system. In 3 cases, selection of ABO type-specific blood based on the current sample would have led to an ABO-compatible transfusion (e.g., correct type A, current type O). In the other 3 cases, an ABO-incompatible transfusion would have resulted (e.g., correct type O, current type A).

Access to a centralized patient database detected 38 percent more ABO typing errors and prevented six mistransfusions, which would not have been prevented at a single institution. Centralization of patient transfusion data should be encouraged.