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

Abstract

BACKGROUND Wrong blood in tube (WBIT) errors are a preventable cause of ABO‐mismatched RBC transfusions. Electronic patient identification systems (e.g., scanning a patient's wristband barcode before pretransfusion sample collection) are thought to reduce WBIT errors, but the effectiveness of these systems is unclear. STUDY DESIGN AND METHODS Part 1: Using retrospective data, we compared pretransfusion sample WBIT rates at hospitals using manual patient identification (n = 16 sites; >1.6 million samples) with WBIT rates at hospitals using electronic patient identification for some or all sample collections (n = 4 sites; >0.5 million samples). Also, we compared WBIT rates after implementation of electronic patient identification with preimplementation WBIT rates. Causes and frequencies of WBIT errors were evaluated at each site. Part 2: Transfusion service laboratories (n = 18) prospectively typed mislabeled (rejected) samples (n = 2844) to determine WBIT rates among samples with minor labeling errors. RESULTS Part 1: The overall unadjusted WBIT rate at sites using manual patient identification was 1:10,110 versus 1:35,806 for sites using electronic identification (p < 0.0001). Correcting for repeat samples and silent WBIT errors yielded overall adjusted WBIT rates of 1:3046 for sites using manual identification and 1:14,606 for sites using electronic identification (p < 0.0001), with wide variation among individual sites. Part 2: The unadjusted WBIT rate among mislabeled (rejected) samples was 1:71 (adjusted WBIT rate, 1:28). CONCLUSION In this study, using electronic patient identification at the time of pretransfusion sample collection was associated with approximately fivefold fewer WBIT errors compared with using manual patient identification. WBIT rates were high among mislabeled (rejected) samples, confirming that rejecting samples with even minor labeling errors helps mitigate the risk of ABO‐incompatible transfusions.

Addressing the identity crisis in healthcare: positive patient identification technology reduces wrong patient events

“…This article by Kaufman and coworkers 18 finds the residual WBIT error rate with ePPID at one in 15,000. It is not clear that this is sufficient to "pull the safety net" of the group check sample.…”

“…This “group check” sample could potentially be eliminated by ePPID if the technology was proven to be highly reliable. This article by Kaufman and coworkers finds the residual WBIT error rate with ePPID at one in 15,000. It is not clear that this is sufficient to “pull the safety net” of the group check sample.…”

“…One in 2326 sounds rare, but for a large hospital, this means that every 2 weeks there is a WBIT error that could lead to the transfusion of ABO‐incompatible blood. The article by Kaufman and colleagues in this issue of TRANSFUSION reports a multicountry audit of more than 2 million blood bank samples collected in 20 hospitals. Their most important observation was that institutions that had implemented near‐patient ePPID for sample labeling had a fivefold lower WBIT rate.…”

“…Their most important observation was that institutions that had implemented near‐patient ePPID for sample labeling had a fivefold lower WBIT rate. Kaufman and colleagues found a residual WBIT error rate of one in 15,000 with ePPID attributable to three deviations: utilizing wristbands not affixed to a patient, failing to immediately apply labels generated at the bedside to samples, and affixing another patient's wristband to the patient. This report confirms other single‐center reports detailing error rates before and after implementation of ePPID technology for the collection of blood samples (with a 1.7‐ to 5.5‐fold safety margin) .…”

“…Health care has been slow to adopt ePPID; even in the article by Kaufman and colleagues, only four (20%) of 20 academic institutions had successfully implemented ePPID. In Canada, only 4% of hospitals in the Transfusion Error Surveillance System had implemented ePPID for blood bank samples .…”