Factors associated with wrong blood in tube errors: An international case series - The BEST collaborative study

Area of Science:

• Clinical Pathology
• Patient Safety
• Healthcare Quality Improvement

Background:

• Wrong blood in tube (WBIT) errors occur when a blood sample does not match the patient identified on the label.
• These errors pose a significant risk, potentially leading to life-threatening ABO mistransfusions.

Purpose of the Study:

• To investigate the incidence, contributing factors, and detection methods of WBIT errors in an international setting.
• To identify key areas for improvement in blood sample collection and patient identification processes.

Main Methods:

• An international, multicenter, descriptive study collected data on WBIT errors from January 2019 to December 2020.
• Data were provided by healthcare facilities across 11 countries, detailing WBIT events and their associated factors.

Main Results:

• 331 WBIT errors were reported from 36 centers, with most detected during pretransfusion testing (58%).
• Errors were nearly evenly split between wrong labeling and wrong patient collection (50% vs. 48%).
• Protocol violations combined with slips/lapses were the most common cause (53%), with the availability of other patients' sample materials during phlebotomy being a frequent factor (61%).

Conclusions:

• Protocol violations and human errors (slips/lapses) are primary drivers of WBIT errors.
• Enhanced sample collection protocols, robust staff education on patient safety, and potentially dual verification methods are recommended.
• Electronic positive patient identification (ePPID) can reduce but not eliminate WBIT errors, suggesting a need for continued vigilance and supplementary safety measures.