Addressing sample identification errors in a multispecialty tertiary care hospital in Bangalore

Area of Science:

• Medical Laboratory Science
• Patient Safety
• Transfusion Medicine

Background:

• Sample identification errors pose a significant risk to patient safety, potentially leading to mismanagement and incorrect administration of blood products.
• Accurate sample identification is critical in healthcare settings to prevent adverse events.

Purpose of the Study:

• To determine the rate of sample identification errors over two years in a multispecialty Indian hospital.
• To evaluate the effectiveness of implemented measures, including bedside blood grouping, in reducing these errors.

Main Methods:

• Implementation of various measures to minimize identification errors during sample collection, processing, and blood administration.
• Introduction of bedside blood grouping using the slide agglutination technique as a risk mitigation strategy.

Main Results:

• The overall sample identification error rate was 48 and 45 per million tests in 2011 and 2012, respectively.
• The blood bank specific error rate decreased from 0.96 to 0.46 per 1000 units issued.
• 81% of errors occurred in inpatients, and 15.6% were repeat errors by the same technicians.

Conclusions:

• Bedside blood grouping, when performed by trained personnel, effectively prevents ABO incompatible transfusions.
• This method also serves as a valuable tool for active surveillance of sample identification errors in hospital settings.