Nancy M Dunbar1, Meghan Delaney2, Michael F Murphy3, Monica B Pagano4, Nabiha Huq Saifee4,5, Jansen Seheult6,7, Mark Yazer6,7, Richard M Kaufman8. 1. Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA. 2. Division Pathology & Laboratory Medicine, Children's National Hospital and Department of Pathology and Pediatrics, The George Washington University, Washington, District of Columbia, USA. 3. NHS Blood & Transplant, and Oxford Biomedical Research Centre, Oxford, UK. 4. Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA. 5. Bloodworks Northwest, Seattle, Washington, USA. 6. Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA. 7. Vitalant, Pittsburgh, Pennsylvania, USA. 8. Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Abstract
BACKGROUND: Wrong blood in tube (WBIT) errors can lead to ABO mistransfusions. It is unknown if WBIT errors are more likely in specific healthcare locations or if specific collection practices influence the commission of WBIT errors. STUDY DESIGN AND METHODS: Data on pretransfusion samples from calendar year 2019 were collected retrospectively by 39 transfusion services in nine countries. We compared the proportion of WBIT errors made in emergency departments (EDs), inpatient wards, and outpatient clinics. RESULTS: In total, 143 WBIT errors were detected among 1,394,862 samples for an unadjusted aggregate WBIT proportion of 1.03/10,000 samples. Using a pooled random effects model, the WBIT proportion was estimated to be significantly higher in EDs (1.23/10,000 samples, 95% CI 0.62-2.43) than inpatient wards (0.71/10,000, 95% CI 0.44-1.14; p < .001) or outpatient clinics (0.24/10,000, 95% CI 0.08-0.65; p < .001) and significantly higher in inpatient wards than outpatient clinics (p = .043). The use of electronic positive patient identification (ePPID) systems was associated with a significantly lower WBIT proportion in the ED (odds ratio, OR: 0.32, 95% CI: 0.11-0.96, p = .041), but not in inpatient wards (OR: 0.45, 95% CI: 0.20-1.01, p = .054) or outpatient clinics (OR: 1.95, 95% CI: 0.39-9.74, p = .415). DISCUSSION: Normalized for the number of samples drawn per location, the WBIT proportion in EDs was 1.7 times higher than inpatient wards and 5.1 times higher than outpatient clinics. EDs represent higher-risk clinical locations for WBIT errors, and electronic positive patient identification (ePPID) may provide a greater impact on safety in EDs relative to other clinical areas.
BACKGROUND: Wrong blood in tube (WBIT) errors can lead to ABO mistransfusions. It is unknown if WBIT errors are more likely in specific healthcare locations or if specific collection practices influence the commission of WBIT errors. STUDY DESIGN AND METHODS: Data on pretransfusion samples from calendar year 2019 were collected retrospectively by 39 transfusion services in nine countries. We compared the proportion of WBIT errors made in emergency departments (EDs), inpatient wards, and outpatient clinics. RESULTS: In total, 143 WBIT errors were detected among 1,394,862 samples for an unadjusted aggregate WBIT proportion of 1.03/10,000 samples. Using a pooled random effects model, the WBIT proportion was estimated to be significantly higher in EDs (1.23/10,000 samples, 95% CI 0.62-2.43) than inpatient wards (0.71/10,000, 95% CI 0.44-1.14; p < .001) or outpatient clinics (0.24/10,000, 95% CI 0.08-0.65; p < .001) and significantly higher in inpatient wards than outpatient clinics (p = .043). The use of electronic positive patient identification (ePPID) systems was associated with a significantly lower WBIT proportion in the ED (odds ratio, OR: 0.32, 95% CI: 0.11-0.96, p = .041), but not in inpatient wards (OR: 0.45, 95% CI: 0.20-1.01, p = .054) or outpatient clinics (OR: 1.95, 95% CI: 0.39-9.74, p = .415). DISCUSSION: Normalized for the number of samples drawn per location, the WBIT proportion in EDs was 1.7 times higher than inpatient wards and 5.1 times higher than outpatient clinics. EDs represent higher-risk clinical locations for WBIT errors, and electronic positive patient identification (ePPID) may provide a greater impact on safety in EDs relative to other clinical areas.