Transfusion sample mislabelling and wrong blood in tube in the UK: Insights from the national comparative audits of blood transfusion in 2012 and 2022

Abstract

AbstractBackgroundSamples for transfusion rejected due to mislabelling can lead to harm when a patient has to be re‐bled or has a transfusion or procedure delayed. Electronic labelling systems which scan the patient's identification band and generate a label at their side aim to reduce mislabelling and misidentification leading to wrong blood in tube (WBIT) errors. The 2022 National Comparative audit of sample collection aimed to compare national rates of sample mislabelling and WBIT to the 2012 audit and to examine the impact of electronic systems.MethodAll UK hospitals were invited to provide data on rejected transfusion samples and WBIT incidents in 1 month (October 2022) and were asked if they had electronic labelling.ResultsTwenty‐three thousand five hundred and eighty‐four rejected samples were reported by 179 sites in 1 month. The rejection rate of 4.4% represents a 47% increase compared to 2012 (2.99%). There were 92 WBIT incidents, an incidence of 1 in 5882 samples—a 45% increase compared to 1 in 8547 in 2012. Twenty‐three percent of sites can print a sample label at the patient's side, up by 224%. The six sites using only electronic sample labelling had a 46.9% lower rejection rate than sites using only hand‐labelling but still reported WBIT.ConclusionsThe increase in sample rejection and WBIT may reflect pressures facing clinical staff, zero tolerance policies and the two‐sample rule. A human factors approach to understanding and tackling underlying reasons locally is recommended. Electronic systems are associated with fewer labelling errors, but careful implementation and training is needed to maximise their safety benefits.