Thursday, 12 February 2015

The consequences of wrong blood in tube errors and suggestions for prevention

Associate Professor Erica Wood has co-authored a paper with researchers from the Serious Hazards of Transfusion UK National Haemovigilance Scheme and the TRIP National Haemovigilance and Biovigilance Office that addresses the critical issue of ‘wrong blood in tube’ errors, in which the blood inside a tube does not correspond to the patient labelled. This error can cause serious consequences, particularly in the case of transfusions, in which an incompatible blood transfusion can lead to the death of the patient.

The paper reviews the many concerns associated with wrong blood in tube errors. Aside from incompatible transfusions (ABO transfusions), mislabeling on samples from donors can lead to incorrect procedures with patients being placed at high risk. Furthermore, misjudged diagnoses for patients’ clinical statuses could result from the issue of wrong blood in tube. Wood and the co-authors discuss the arduous process of identifying the patient whom the blood belongs to which results in treatment delays for patients.

The researchers identified the use of electronic systems from the beginning till the completion of the sampling process as a potentially successful intervention to address the error of incorrect labeling. Furthermore, the introduction of a group-check sample has been raised; however, the authors concede that this will not eliminate all labeling errors. Ineffective communication and training were mentioned as human factors that can result in wrong blood in tube errors.

To address this issue, training programs can be introduced to raise awareness of the possibility of making such mistakes in a medical environment. It is also stated that there is a need to implement new systems and shift processes to reduce the prevalence of wrong blood in tube errors, whilst accounting for the risk of human miscalculations in an environment where there are several risk factors. 

The paper concludes that before an intervention can be fully implemented, further long term studies should be conducted, along with an assessment to ensure efficacy of the strategy. The need to correctly label blood samples is crucial to ensure that patients are not placed at risk now and in the future. 

The review can be read in full here.


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