TY - JOUR
T1 - Wrong blood in tube - potential for serious outcomes: can it be prevented?
AU - Bolton-Maggs, Paula H B
AU - Wood, Erica Michelle
AU - Wiersum-Osselton, Johanna C
PY - 2015
Y1 - 2015
N2 - `Wrong blood in tube? (WBIT) errors, where the blood in the
tube is not that of the patient identified on the label, may lead
to catastrophic outcomes, such as death from ABOincompatible
red cell transfusion. Transfusion is a multistep,
multidisciplinary process in which the human error rate has
remained unchanged despite multiple interventions (education,
training, competency testing and guidelines). The most
effective interventions are probably the introduction of endto-end
electronic systems and a group-check sample for
patients about to receive their first transfusion, but neither of
these eradicates all errors. Further longer term studies are
required with assessment before and after introduction of the
intervention. Although most focus has been on WBIT in relation
to blood transfusion, all pathology samples should be identified
and linked to the correct patient with the same degree of care.
Human factors education and training could help to increase
awareness of human vulnerability to error, particularly in the
medical setting where there are many risk factors
AB - `Wrong blood in tube? (WBIT) errors, where the blood in the
tube is not that of the patient identified on the label, may lead
to catastrophic outcomes, such as death from ABOincompatible
red cell transfusion. Transfusion is a multistep,
multidisciplinary process in which the human error rate has
remained unchanged despite multiple interventions (education,
training, competency testing and guidelines). The most
effective interventions are probably the introduction of endto-end
electronic systems and a group-check sample for
patients about to receive their first transfusion, but neither of
these eradicates all errors. Further longer term studies are
required with assessment before and after introduction of the
intervention. Although most focus has been on WBIT in relation
to blood transfusion, all pathology samples should be identified
and linked to the correct patient with the same degree of care.
Human factors education and training could help to increase
awareness of human vulnerability to error, particularly in the
medical setting where there are many risk factors
UR - http://onlinelibrary.wiley.com.ezproxy.lib.monash.edu.au/doi/10.1111/bjh.13137/pdf
U2 - 10.1111/bjh.13137
DO - 10.1111/bjh.13137
M3 - Article
VL - 168
SP - 3
EP - 13
JO - British Journal of Haematology
JF - British Journal of Haematology
SN - 0007-1048
IS - 1
ER -