Electronic patient identification for sample labeling reduces wrong blood in tube errors.

Area of Science:

• Transfusion Medicine
• Patient Safety
• Laboratory Science

Background:

• Wrong blood in tube (WBIT) errors are a preventable cause of ABO-mismatched red blood cell (RBC) transfusions.
• Electronic patient identification systems aim to reduce WBIT errors, but their effectiveness requires further investigation.

Purpose of the Study:

• To evaluate the effectiveness of electronic patient identification systems in reducing WBIT errors.
• To compare WBIT rates between manual and electronic patient identification methods.
• To assess WBIT rates in mislabeled samples to understand their contribution to transfusion errors.

Main Methods:

• Retrospective analysis comparing WBIT rates at hospitals with manual versus electronic patient identification.
• Prospective typing of mislabeled samples to determine WBIT rates in samples with minor labeling errors.
• Evaluation of WBIT error causes and frequencies at individual sites.

Main Results:

• Electronic patient identification was associated with approximately a fivefold reduction in WBIT errors compared to manual identification (adjusted WBIT rates: 1:14,606 vs. 1:3046).
• Significant variation in WBIT rates was observed among individual sites.
• Mislabeled (rejected) samples showed a high WBIT rate (1:71 unadjusted, 1:28 adjusted), highlighting the importance of sample rejection protocols.

Conclusions:

• Electronic patient identification systems are effective in reducing WBIT errors during pretransfusion sample collection.
• Rejecting samples with even minor labeling errors is critical for mitigating the risk of ABO-incompatible transfusions.
• Continued vigilance and implementation of robust identification systems are essential for transfusion safety.