'Wrong blood in tube': solutions for a persistent problem

This study was performed to determine the incidence of 'wrong blood in tube' (WBIT)-type errors at our institution during the past 5 years, to analyse their root cause and to evaluate the efficacy of preventive measures that have been implemented since 2006.

All reports of mislabelled and miscollected specimens detected between January 2005 and December 2009 were reviewed. Of these, WBIT-type errors were further analysed as they represent a major risk for mistransfusion.

Between 2005 and 2009, 59,373 type and screens were performed at our institution and a total of 26 major errors (WBIT) were identified. Of the errors, eight were detected by discrepant typing results (in comparison with historic blood type), six were discovered by the clinical service and 12 were identified in the blood bank by other means. Our estimated 'raw' WBIT rate (1 in 2283 samples) is comparable to that (1:2262) in the published literature. Since 2006, our nursing policy mandates that 'all type, screen and cross will have two witnesses to the correct ID of the patient and labeling is done at the bedside at the time of the draw.' This has reduced (from 11 in 2006 to 5 in 2007), but did not eliminate, our WBIT problem that persisted into 2008 and 2009 (three and seven incidents, respectively). Since 2009, we also require a second, independently drawn sample in previously un-typed patients who are likely to be transfused.

We conclude that WBITs continue to represent a leading cause of potential mistransfusions at our institution. Changes in nursing (two witnesses to correct ID) and/or blood bank policy (check-type with a second specimen) may reduce, but not eliminate, this persistent problem. Clearly, additional safety measures are required to prevent WBIT-type errors.