Labeling Blood Samples There are documented occurrences and near - - PowerPoint PPT Presentation

Labeling Blood Samples – Getting It Right

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Labeling Blood Samples

There are documented occurrences and near misses of mislabeling of blood samples (for example type and screen) = Potential for serious harm to the patient!

The Process

Manitoba Transfusion Medicine Best Practice Resource Manual for Nursing:

“There shall be unequivocal identification of the intended recipient before drawing blood specimens using the patient armband or Provincial Health Card. Includes:

• The patient’s last and first name
• Personal Health Identification Number (PHIN) or
• Unique identifier , if there is no PHIN”

The Process

• Blood specimens shall be labeled in the

patient’s presence

• Label includes name, PHIN (or unique

identifier) and date of collection

• Label must be attached to the specimen tube

before leaving patient’s side

• Request form is prepared with correct patient

identifiers

• Perform final check that specimen, requisition

and patient’s armband are all identical

How does mislabeling occur?

When a blood sample is drawn from the patient…

The main issue appears to be 1 of 2 scenarios:

Scenario #1

• A pre-labeled specimen tube with another

patient’s information is used to collect blood.

• The patient information is not reconciled at

the bedside with the patient’s identification

• n their armband.
• As a result, the patient info on the blood

sample may not match the patient who actually had their blood drawn.

Scenario #2

• An unlabeled specimen tube is used to collect

blood.

• The unlabeled specimen tube is taken out of

the room, and then the specimen is labeled with a different patient’s information.

• As a result, the patient info on the blood

sample will not match the patient who actually had their blood drawn.

How is mislabeling discovered?

• By the unit
• By the lab
• By CBS

Reported Events

2014 Data: Incidents reported related to

• mislabeling of specimens or

requisitions

• or wrong patient blood draw

HSC:

45 Occurrences 13 Near Misses

SBGH:

18 Occurrences 0 Near Misses

Occurrence #1

• Blood work drawn on patient in bed 10.

Unlabeled tube handed to unit clerk and told it was bed 10’s blood work.

• Blood tubes mistakenly labeled with Bed 5’s

addressograph and submitted. Error noted when the nurse of Bed 5 received blood work results and knew that no blood work was

• rdered for that patient.
• Blood work had to be redrawn on patient in

Bed 10.

Occurrence #2

• CBS received a type and screen sample for a patient.

(Jane Smith) The sample was O positive.

• Their previous records stated that Jane Smith was A

positive.

• CBS contacted the ward and it was confirmed that the

blood sample was taken from another patient and mistakenly stamped with Jane Smith’s information.

• If there had not been a previous blood group on file, it

could have resulted in a fatality in the event this patient was transfused.

• Also resulted in a delay for the other patient who

required the type and screen to receive a life-saving blood transfusion.

Occurrence #3

• Post partum patient required urgent Type and Screen

for emergent OR

• An unlabeled tube was used so the step to verify the

label to the patient’s armband was not done.

• Another nurse assisted with labeling and sending the

specimen due to the urgency of getting to the OR.

• The wrong addressograph was used to label the

sample and requisition.

• Incident was discovered by the unit and

communicated to Blood Bank who let CBS know to stop report.

Occurrence #4

• A verbal request for group and match for transfusion received by

phlebotomist for Patient A

• Proceeded to multi-patient area (day procedure) to locate patient

identified as sitting in 3rd chair {Patient B sitting in this chair}

• Group and match drawn and brought to main desk for labeling from

requisition

• Requisition correctly made for Patient A requiring transfusion
• Sample labeled with Patient A
• Cross match blood arrived, checked and administered
• Transfusion reaction occurred
• Post transfusion reaction protocol discovered original A+ match was not

same as post reaction sample of O+

• Fortunately Patient A had precautionary antihistamine treatment

secondary to the medication he was receiving so the effect of the wrong blood was mitigated – however he did require a 32 hour stay in hospital

Patient Safety Impact of mislabeled Type & Screen

Infrequent event but has potential to cause significant harm

• Redraw of Type & Screen
• Delay in blood transfusion
• Increase in the use of Emergency Blood
• Wrong blood type transfused in a patient with

increase in morbidity and mortality

• can cause acute hemolysis due to ABO incompatibility

Impact on Resources & Workload

For the Blood Bank lab:

• Notification of unit, CBS etc
• Work associated with reprocessing an additional

T&S specimen (accessioning, packaging, shipping to CBS etc)

• Documentation of rejected

specimen, initiate NCR

Impact on Resources & Workload

For the Unit

• Notification of lab, physician, patient, follow up

with staff involved

• Work associated with recollection of a new

specimen& requisition on correct patient

• Documentation in patient record, initiation
• f an Occurrence Report

Impact on Resources & Workload

For CBS

• Notification of lab, Medical Director

communicates with clinical area via letter

• Work associated with investigation of descrenpant

results, processing a new specimen& requisition

• n correct patient
• Documentation re rejected specimen, initiation
• f an NCR

Solutions

Review your process Compare to Identify the Gaps – Commit to Action

• Blood specimens shall be labeled in the patient’s

presence

• Label includes name, PHIN (or unique identifier) and

date of collection

• Label must be attached to the specimen tube before

leaving patient’s side

• Request form is prepared with correct patient

identifiers

• Perform final check that specimen, requisition and

patient’s armband are all identical

Discussion and Questions