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

Background A wrong blood in tube (WBIT) error signifies a blood sample that does not match the patient identified on the sample label. WBIT errors can result in ABO mistransfusions. Study design and methods In this international, multicenter, descriptive study, healthcare facilities provided detailed information on WBIT errors occurring from 1/1/2019 to 12/31/2020. Factors contributing to WBIT errors were classified as protocol violations, knowledge gaps, and slips/lapses. Results 331 WBIT errors were compiled from 36 centers in 11 countries. WBIT errors were most frequently detected through pretransfusion sample testing (191, 58%), with 38 (20%) detected by a second (check) sample. WBIT errors were divided almost evenly between intended patient drawn/wrong label applied (166, 50%) and wrong patient drawn/intended label applied (158, 48%). Information on contributing factors was available for 260 WBIT errors; most involved a combination of protocol violations and slips/lapses (139, 53%). The most frequent contributing factor was another patient's sample labels or tubes being available during phlebotomy (61%). Protocol violations were more likely to result in wrong patient being drawn (p = .0007). In 43 WBIT errors, electronic positive patient identification (ePPID) was not used when available or was used incorrectly. Conclusions Protocol violations and slips/lapses frequently contribute to WBIT errors. Sample collection processes should be designed to minimize error opportunities; staff should be educated on why protocol compliance is critical for patient safety. Using ePPID does not eliminate all WBIT errors. Institutions using ePPID may elect to require check sample verification as an added safety measure.

Automated summary

In this study, a total of 331 wrong blood in tube (WBIT) errors were compiled from 36 centers in 11 countries, with most errors detected through pretransfusion sample testing. The most common contributing factors to WBIT errors were protocol violations and slips/lapses. The conclusion emphasizes the need for sample collection processes to be designed to minimize error opportunities and for staff to be educated on the critical importance of protocol compliance for patient safety.