National Wrong Blood In Tube - Irish Blood Transfusion Service

National Wrong Blood In Tube
(WBIT) Survey
Results and feedback
Mr John Sheehy, BSc(Hons), MSc, FAMLS
NHO Conference Friday 11th November, 2011,
Radisson Blu Royal Hotel, Golden Lane, Dublin 8

Background
• Southern Haemovigilance Working Group query
• Do the NHO want Wrong Blood In Tube (WBIT)
incidents reported as a SAE?
• NHO response
• Reluctant to collate reports due to
– Staffing constraints
– Potential sizeable workload
• Proposed a national survey
– To establish a baseline
– Invited my participation (member of Transfusion &
Transplantation Science Advisory Body – TTSAB)

Objectives
• The primary aim of this national study was to
assess the frequency of mislabelled and
miscollected (i.e. WBIT) samples submitted to
hospital blood banks in Ireland
• Survey carried out over a three month period (Jun,
Jul, Aug 2011)
• To access the availability of policies and training on
blood transfusion sampling in Irish hospitals.
• To assess who takes samples for blood transfusion
in Irish hospitals
• To propose solutions to minimise problem

Participation rate
• 79 hospitals transfuse red cells In Ireland
(figure from ANSAE/ANSAR reports)
• Response from 41hospitals
– 40 respondents themselves
– 1 respondent did not identified
• Response rate 52%

National Wrong Blood In Tube
Section 1:
(WBIT) Survey
Results and feedback
Policies, procedures and training

Does the hospital have a written policy
with explicit criteria for acceptance of
samples for blood transfusion?
98%
2%
Yes No
40 Yes
1 No

Does your hospital have a written policy
on sampling for blood transfusion?
100%
41 Yes
0 No
YES

Is training provided in your hospital for staff
involved in sampling for blood transfusion?
30
25
20
15
10
5
0
27
14
All Some None
0

Is training provided in your hospital for staff
involved in sampling for blood transfusion?
• Comments
– Submitted by 19 respondents (all respondents
had option)
• Challenges in delivering training to doctors
including locum doctors (11 comments)
• Other comments referred to staff not receiving
training specifically in the act of venepuncture
• Generally where midwives / nursing / phlebotomy
involved training is provided

35
30
25
20
15
10
5
0
Who delivers training on sampling for
blood transfusion in your hospital?
35 35
Haemovigilance
Haemovigilance
Officer
Officer
6
Medical Medical Scientist Scientist Nursing/Midwifery
Nursing/Midwifery
Staff
Staff
4
38 respondents
3 non-respondents
3
Medical Medical Staff
Staff

Who delivers training on sampling for
blood transfusion in your hospital?
• Comments
– Submitted by 18 respondents
• 9 comments referred to the involvement of
phlebotomy staff in training in venepuncture -
• 2 comments referred to the use of SNBTS elearning
programme

Who is permitted to take transfusion samples
in your hospitals? (both routine and emergency)
40
35
30
25
20
15
10
5
0
38
Phlebotomist
34
0
Medical Scientific Staff
1
33
Nursing /Midwifery Staff
34
2
Medical student
2
40
Intern/House Officer / Registrar
40
33
Consultant
36
41 respondents
Parents, perfusionists,
healthcare assistants, nurses
working in specialist areas
3
General Practitioner
1
10
Other
Routine Emergency
7

National Wrong Blood In Tube
Section 2:
(WBIT) Survey
Results and feedback
Specimen rejection rates

What number of samples are received in
the hospital blood bank per annum (2010)?
16
14
12
10
8
6
4
2
0
6
16 16
5
40 respondents
1 non-respondents
< 1000 1000 - 5000 5001 - 10,000 10,001 - 15,000 >15,001
Small to medium sized hospital Medium to large sized hospital
6
7

Total specimens received and rejected
June – August 2011
Jun ’11
Jul ’11
Aug ’11
Total for
3-month period
Samples
received
24,082
23,374
23,858
71,314
Samples
rejected
944
1,004
974
2,922
Average rejection
rate per month
3.9%
4.3%
4.1%
4.1%
(or 1 in 24
specimens)

1,200
1,000
800
600
400
200
62
Why were samples rejected?
6
Unlabeled Illegible /
Unreadable
1,181 1,181
1,181
Incomplete or
missing
information on
sample tube
and / or
request form
Mismatched
information
between sample
tube and
request form
2922 rejected specimens
Increased use of electronic
Suggestions to reduce ordering these rejection RFID systems errors??
National
Standardise
blood
policy
transfusion
nationally
request
on addressograph
form
labels
Increased use of electronic
No excuse!!
ordering RFID Confusion systems re use of
No excuse!! addressograph labels
Education
No excuse!!
437 437
437
Standardise MCRN??
policy
nationally
194
194
Addressograph
label used to
label tube
248
248
Sample tube
and / or
request form
not clearly
signed.
746
746
Other

How do we compare with international
figures for mislabelled specimens?
• Murphy et al, Transfus Med, 2004 UK study
• Rejection rate of 3.2%
– “…identified great variation in policies and practice for sample
collection..”
– “…practice Or can allowing we additions learn or from changes the to sample best tubes &
request forms varied …”
– “…regular performing tracking of the Irish rates of specimen hospitals? rejection could be
used to identify poor performance in individual hospitals…”
Further analysis of our own data!!
• Dzik et al, Vox Sang, 2003, 10-country
worldwide study
• Rejection Rate of 0.2% to 1.7%
– “…great variation worldwide in the reported frequency of
mislabelled samples, probably representing from variation in
policies for sample acceptance..”

Total specimens received and rejected
June – August 2011
Jun ’11
Jul ’11
Aug ’11
Total for
3-month period
Samples
received
24,082
23,374
23,858
71,314
Samples
rejected
944
1,004
974
2,922
Average rejection
rate per month
3.9%
4.3%
4.1%
4.1%
(or 1 in 24
specimens)
Range in rejection rate for the hospitals
who responded is 0.0% to 10.85%

Number
Number
31
24
16
35
32
17
3
4
20
2
10
34
28
14
37
1
22
38
36
39
Response Response Date
Date
Oct 12, 2011 9:53 AM
Oct 12, 2011 10:16 AM
Oct 12, 2011 10:40 AM
Oct 12, 2011 8:42 AM
Oct 12, 2011 9:47 AM
Oct 12, 2011 10:39 AM
Oct 13, 2011 9:33 AM
Oct 12, 2011 11:27 AM
Oct 12, 2011 10:22 AM
Oct 13, 2011 9:37 AM
Oct 12, 2011 10:56 AM
Oct 12, 2011 8:49 AM
Oct 12, 2011 10:01 AM
Oct 12, 2011 10:47 AM
Sep 9, 2011 12:11 PM
Oct 13, 2011 9:42 AM
Oct 12, 2011 10:19 AM
Sep 8, 2011 12:52 PM
Sep 13, 2011 2:57 PM
Sep 5, 2011 8:42 AM
June June 2011
2011
318
368
285
1623
646
1349
64
75
1028
1787
137
131
338
320
946
515
951
1320
1113
607
July July 2011
2011
302
400
220
1704
590
1296
52
77
1144
1616
150
150
296
327
1007
490
883
1234
1160
563
Aug Aug-11 Aug Aug 11
311
365
222
1652
622
1337
67
44
1124
1655
158
148
307
296
1018
504
957
1277
1200
548
Total Total no. no. of of specs
specs
931
1133
727
4979
1858
3982
183
196
3296
5058
445
429
941
943
2971
1509
2791
3831
3473
1718
Total Total rejected
rejected
101
109
69
450
164
348
15
15
248
274
23
22
41
36
108
53
92
121
101
46
% % rejected
rejected
10.85%
9.62%
9.49%
9.04%
8.83%
8.74%
8.20%
7.65%
7.52%
5.42%
5.17%
5.13%
4.36%
3.82%
3.64%
3.51%
3.30%
3.16%
2.91%
2.68%

Number
Number
8
9
27
15
18
40
30
33
13
25
21
12
29
19
5
26
7
23
11
6
Response Response Date
Date
Jun Jun 2011
2011
318
368
285
1623
Jun Jun 2011
2011
761
398
568
274
Oct 12, 2011 11:00 AM
Jul Jul Jul 2011
2011
Oct 12, 2011 10:58 AM
302
Oct 12, 2011 10:04 AM
Oct 12, 2011 10:42 AM
400
Oct 12, 2011 10:36 AM
Sep 2, 2011 10:48 AM
220
Oct 12, 2011 9:55 AM
Oct 12, 2011 8:59 AM
1704
Oct 12, 2011 10:50 AM
Oct 12, 2011 10:08 AM 52
39
53
Oct 12, 2011 10:21 AM 159
121
156
LOW rejection rates
Oct 12, 2011 10:52 AM
Jul Jul Jul 2011 2011
2011
Oct 12, 2011 10:00 AM 141
Aug 2011
Oct 12, 2011 10:25 AM
735
Oct 12, 2011 11:09 AM
Oct 12, 2011 10:05 AM
401
Oct 12, 2011 11:02 AM
Oct 12, 2011 10:17 AM
497
Oct 12, 2011 10:54 AM
280
Oct 12, 2011 11:06 AM
HIGH June June 2011 2011
2011 rejection July July July 2011
2011 Aug Aug-11 Aug 11 11
rates Total Total Total no. no. of of specs
specs
905
Aug Aug 2011
2011
269
1263
311
1403
300
365
530
152 222
2366
1652
199
369
Aug 2011
50
761 820
398
568 407
274
507 2
0
293
Total Total Total 865 no. no. no. of of 860specs
specs
specs
(3 (3-mths) (3
mths) mths)
232
1217
1358
300
540
105
2280
179
399
58
735
401
497
280
4
0
236
931
1266
1437
300
1133
581
727
106
2233
4979
214
398
Total Total no. no. of of specs specs
specs
103
105
(3 (3-mths) (3
mths)
67
820 2316
407
507 1206
293
1572 6
1
847
2630 Total
Total
rejected
rejected
737
101
3746
4198
900
109
1651
363
6879
450
592
144
436
1166
175
2316
1206
1572
847
12
1
69
Total
Total
349
rejected
rejected
22
10
9
2
Total Total rejected
rejected
65
% % rejected
rejected
17
79
10.85%
85
16
9.62%
29
6 9.49%
109
9.04%
9
2
6
14
4
% rejected
% rejected
2
22 0.95%
10
9 0.83%
2
0.57%
0
0
0.24%
% % rejected
rejected
2.47%
2.31%
2.11%
2.02%
1.78%
1.76%
1.65%
1.58%
1.52%
1.39%
1.38%
1.20%
1.15%
1.14%
0.95%
0.83%
0.57%
0.24%
0.00%
0.00%

National Wrong Blood In Tube
Section 3:
(WBIT) Survey
Results and feedback
Wrong Blood In Tube (WBIT) incidents

Wrong Blood In Tube (WBIT)
• Some confusion when survey initially sent out
• Initially we were defining WBIT as any incident
where the wrong blood was detected through a
different historical blood group
• We then sought information of all WBITs
irrespective of how determined .i.e.
– either through a different historical blood group
– notification/communication from clinical area
– identified in laboratory through ‘other’ means

Total specimens received & WBIT incidences
June – August 2011
Jun ’11
Jul ’11
Aug ’11
Total for
3-month period
Samples
received
24,082
23,374
23,858
71,314
No. of WBIT
Incidences
4
5
6
15
Average incidence
of WBIT per month
0.017%
0.021%
0.025%
0.021%
(or 1 in 4,743
specimens)

10
9
8
7
6
5
4
3
2
1
0
WBIT incidences
How were they detected?
9
Different
historical
blood group
4
Information
received from
sampler
Investigation
'triggered' in
blood bank
1 1
Detected due
to mislabelling
of sample

10
9
8
7
6
5
4
3
2
1
0
8
Emergency
Dept
WBIT incidences
Where did they occur?
A WBIT can occur throughout the hospital
but there ‘appears’ to be a higher
incidence in the Emergency Dept.
Care has to be taken with this finding as
we did not collect how many specimens
were collected in each area of the hospital
0 0 0 0 0
Theatre ITU Day Ward Out Patients
Dept
Neonatal
Unit
7
'Routine'
Ward

12
10
8
6
4
2
0
WBIT incidences
Who took the specimens?
Medical NCHD staff ‘appear’ to be the staff grade
involved in most WBIT incidents
11
This is what one would expect as they take the most
samples
Slightly disappointing though is the finding that as most
respondents would have stated that where nursing /
midwifery receive specific training, this staff grade
accounted for 27% of the 4 WBITs reported
No phlebotomy staff involved 27% in WBIT
0 0
Phlebotomist Medical
Scientist
Nurse /
Midwife
73%
0 0
NCHD Consultant 'Other'

How do we compare with international
figures for WBIT specimens?
• Dzik et al, Vox Sang, 2003, 10-country worldwide
study
• WBIT Rate of 0.03% to 0.09%
– “…greater variation worldwide in reported frequency of
mislabelled samples …incidence of WBIT occurred at a
more constant rate..”
• Ansari & Szallasi, Vox Sang, 2011, US study
• WBIT Rate of 0.04%
• Grimm et al, Arch Pathol Lab Med, 2010, US study
• WBIT Rate of 0.04%

Total specimens received & WBIT incidences
June – August 2011
Jun ’11
Jul ’11
Aug ’11
Total for
3-month period
Samples
received
24,023
23,326
23,797
71,146
No. of WBIT
Incidences
4
5
6
15
Average rate of
WBIT per month
One hospital accounted for 3 of the 15 WBIT
incidences reported in this survey
0.017%
0.021%
– a WBIT rate of 0.2% (or 1 in 503 specimens)
0.025%
0.021%
This hospital had a mislabelling rate of 3.5%
(or 1 in 4,743
specimens)
Range in WBIT incidences for the hospitals
who responded is 0.0% to 0.2%

What have we learned from the study?
• All respondents have policies and
procedures
• Training to the samplers is provided
though with difficulty gaining access to
medical staff
• The data for mislabelling of specimens
and WBIT incidents is comparable with
international findings though with some
variations

Where to go from here??
• Does Ireland need a national common blood transfusion
request form?
– Who will design it?, will we be able to agree?
• Does Ireland need a national common policy on sample
acceptance, minimum requirements, use of
addressograph label on request from etc,?
• Will the use of electronic RFID help reduce the problem?
• Does the use of phlebotomy staff help to reduce the
error rate?
• Does a zero-tolerance approach to mislabelling help to
reduce the error rate?
• How can some hospitals achieve a mislabelling rate of

Any Questions?
Or more importantly any
suggestions?????
……..Thank you!!!!