Source · HSSIB Patient Safety Investigation

Wrong patient details on blood sample

Published 11 June 2021 Launched 16 May 2019 Published HSIB Legacy

Checking Medical tests

Wrong blood in tube (WBIT) incidents can occur when blood samples are taken from patients and are either miscollected (blood is taken from the wrong patient but labelled with the correct patient details) or mislabelled (blood is taken from the intended patient but labelled with the incorrect patient details).

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Summary

1 recommendation 6 learning prompts 1 of 1 responded

Safety Recommendations

1 total

Recommendation 1 NHSX

It is recommended that NHSX should take steps to ensure the adoption and ongoing use of electronic systems for identification, blood sample collection and labelling.

NHSX will communicate the need for digital systems for blood sample identification and labelling to all trusts, providing best practice blueprints as part of broader digital transformation work.

Response received 14 January 2020

The ambition of NHSX is for every NHS trust to use digital systems to maximise the quality and safety of care. This requirement clearly includes having safe systems in place for the identification, labelling and tracking of blood samples. We will ensure that the need to have such systems in place is communicated to all trusts as part of our work on defining good practice in digital transformation. A number of blueprints developed through our GDE [Global Digital Exemplars] and Fast Follower programme set out how this can best be achieved. We will make sure they are available to all trusts as an effective means of sharing best practice on the issue. Response received on 14 January 2020.

Learning Prompts

6 total

Prompt 1 Learning prompt Trusts can seek to understand ‘work as done’ by staff and take a safety science approach when developing blood sampling and labelling policies.

Prompt 2 Learning prompt Trusts can aim to incorporate human factors thinking and awareness within incident reporting and investigation.

Prompt 3 Learning prompt Trusts should be aware of the increased risk of WBIT incidents occurring where there may be staff shortages and staff fatigue.

Prompt 4 Learning prompt Trusts can ensure that local policies and training on blood sampling account for the challenges posed by different working environments.

Prompt 5 Learning prompt Trusts can aim to understand the range of distractions staff face in different working environments and the compromises staff may have to make to deliver patient care.

Prompt 6 Learning prompt Trusts can optimise the availability, accessibility and usability of appropriate equipment used in blood sampling and labelling (for example: computer terminals, printers, bedside tables, sampling equipment, and that equipment is maintained).