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Reducing the risk of mistransfusion.

To the Editor--We would like to update our experience in reducing the risk of mistransfusion. (1) In our earlier report, (2) we collected data on mislabeled blood bank samples, classified by severity and by location. Overall, the incidence of mislabeling was 0.5%; about one-third of these events involved miscollected specimens discovered when an ABO/Rh result on a current specimen did not match the historical blood type on file, also known as "wrong blood in tube" (WBIT) samples. Targeting patient care areas contributing to recurring WBITs with timely feedback led to a decrease in the number of WBIT specimens. Subsequent to the initial effort, we implemented a 2-signature requirement for all blood bank samples. The number of WBIT cases has decreased from an average of 5.8 per quarter to 2.3 per quarter (see Figure). Although our ultimate goal is to use electronic bar code specimen labeling at the bedside, which has been demonstrated to reduce misidentification of clinical laboratory samples, (3) followed by an electronic blood unit verification system, (4) we are gratified that a "low-tech" strategy, in conjunction with continued education among laboratory and nonlaboratory phlebotomists, can reduce the risk of mistransfusion. We plan to trend our future efforts using statistical process control tools. (5)

(1.) College of American Pathologists Commission on Laboratory Accreditation, Laboratory Accreditation Program. Transfusion Medicine Checklist. TRM.30575. Revised September 27, 2007. Northfield, IL: College of American Pathologists; 2007.

(2.) Quillen K, Murphy K. Quality improvement to decrease specimen mislabeling in transfusion medicine. Arch Pathol Lab Med. 2006;130(8):1196-1198.

(3.) Hayden RT, Patterson DJ, Jay DW, et al. Computer-assisted bar-coding system significantly reduces clinical laboratory specimen identification errors in a pediatric oncology hospital. J Pediatr. 2008; 152(2):219-224.

(4.) Staves J, Davies A, Kay J, Pearson O, Johnson T, Murphy MF. Electronic remote blood issue: a combination of remote blood issue with a system for end-to-end electronic control of transfusion to provide a "total solution" for a safe and timely hospital blood transfusion service. Transfusion. 2008;48(3): 415-424.

(5.) Dzik WS, Beckman N, Selleng K, et al. Errors in patient specimen collection: application of statistical process control. Transfusion. 2008;48(10): 2143-2151.

The authors have no relevant financial interest in the products or companies described in this article.



Department of Laboratory Medicine

Boston University Medical Center

Boston, MA 02118

Number of wrong blood in tube (WBIT) cases per quarter. The 2
interventions included targeted feedback (identifying patient
care areas contributing to WBITs) and 2-signature requirement for
all blood bank specimens.

       2nd Qtr.    7
       3rd Qtr.   10
       4th Qtr.   13
2006   1st Qtr.    8
       2nd Qtr.    4
       3rd Qtr.    6
       4th Qtr.    4
2007   1st Qtr.    6
       2nd Qtr.    7
       3rd Qtr.    3
       4th Qtr.    1
2008   1st Qtr.    3
       2nd Qtr.    2

Note: Table made from line graph.
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Title Annotation:Letters to the Editor
Author:Quillen, Karen; Murphy, Kate
Publication:Archives of Pathology & Laboratory Medicine
Article Type:Letter to the editor
Date:Feb 1, 2009
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