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Survey on Detected "Wrong Blood in Tube" Events Based on Data from German Blood Establishments: A Feasibility Study
Hengameh Aghili Pour1, Sarah Anna Fiedler1, Jochen Hoch2
1Division of Safety of Biomedicines and Diagnostics, Paul-Ehrlich-Institut, Langen, Germany.
Introduction:
"Wrong blood in tube" (WBIT) describes the discrepancy of patient identity between tube label and tube content. WBIT events can lead to an incompatible transfusion and may have serious consequences for the patient. There are currently no comprehensive evaluations or analyses of WBIT events in Germany. This study is conducted as a feasibility study. The detected WBIT (dWBIT) events from 2020 to 2023 were retrospectively recorded and analyzed.
Methods:
The reporting of this study is guided by the Checklist for Reporting of Survey Studies (CROSS). It is not mandatory to report WBIT events to a central supervisory authority in Germany. Therefore, a cooperation with four blood establishments (BEs) took place. The data were collected using a data collection form. The survey contains a total of 14 questions about each dWBIT event. A database was created in FileMaker 2023 for data storage and plausibility checks.
Results:
In the 4 years under review, there were a total of 125 dWBIT events in the four cooperating BEs. The rate of dWBIT events results in an overall rate of one dWBIT per 4,530 blood group determinations. Frequencies varied between emergency room (1:6,897), outpatient ward (1:3,866), regular ward (1:2,564), and intensive care unit (1:863). The main reason for the error was incorrect labeling of the collection tube (19%) and blood sample taken from the wrong patient (32%). In most cases, the error was noticed in the laboratory (94%), and in 5% directly after the sample was taken. dWBIT events occurred in 87% of patients with a known blood group and in 13% of patients with a first blood group determination. The time of sampling for blood typing (time of day, day of the week, or weekend) had no influence on the dWBIT rate. None of these WBIT cases led to an ABO-incompatible transfusion.
Conclusion:
The study examines the frequency of dWBIT incidents in Germany for the first time and shows that these cases continue to represent a relevant risk, especially with regard to incompatible transfusions. Measures to minimize risk could include improving the training of transfusion staff in combination with IT-based identification and two independent blood samples for blood group typing.
