This case concerns patient misidentification due to errors made at specimen collection. Specifically, the collector interchanged two recipient specimen tubes after having broken standard operating procedure (and safety standards that require specimens to be labelled at the bedside) by pre-labelling them prior to collection. The case will be discussed as follows:
- Importance of identification to transfusion
- Role of patient records
- How to handle discrepancies with records
Importance of Identification to Transfusion
The most common cause of acute hemolytic transfusion reactions is patient misidentification. Such errors can lead to patients being transfused with donor blood of the wrong ABO group, resulting in severe hemolysis.
In this case, the first sample labelled with patient OP's identification information (but containing AW's blood) typed as Group A Rh positive and was crossmatched successfully with group A RBC. If transfused, OP could have experienced a life-threatening hemolytic reaction.
Where can patient misidentification occur?
Of all the stages when misidentification can occur, errors most typically occur when collecting pretransfusion specimens and when identifying patient and donor units prior to transfusion. Because this case deals with errors made at specimen collection, the discussion will focus on identification protocols at this stage of the transfusion process.
The following identification protocols are examples of suitable specimen collection practices. (Practices are not meant to be all-inclusive or prescriptive. Individuals should always adhere to the policies developed in their institutions.)
- Identification band. The patient should be wearing an identification band. If not, some hospitals use unique transfusion/blood bank (BB) identification bands consisting of a BB number that can be attached to the patient's arm or ankle, blood specimen, crossmatch requisition, and donor blood tags. A match of the number on the transfusion tag with the ID band number on the patient increases transfusion safety by establishing positive, continuous identification between patients, their specimens, and crossmatched RBC units.
- Patient identification. Many facilities require that the patient be identified by two people, one of whom is the blood collector. The other person may be the patient (if they are at least 18 years old and competent to do so), a nurse, or a member of the patient’s family. A suitable protocol would be to:
- Ask the patient to spell or verbalize his/her first and last name and date of birth (DOB). If impossible due to the patient’s age or condition, a responsible adult such as relative, nurse or physician may identify the patient. Note: the DOB and the patient's name are the only identifiers that a patient or family member can verify.
- The person who identifies the patient must sign the phlebotomy record (crossmatch requisition) in the appropriate place, indicating their title or relationship to the patient.
- Identity comparison with requisition/labels. Prior to drawing blood specimens, the information on the identification band must be compared to the information on the requisition and any preprinted labels (or for institutions using electronic test/order entry, to the information on the specimen labels). If the information does not coincide, the specimen should not be collected until the discrepancy is resolved. In an emergency, policies should exist for providing un-crossmatched blood until accurate identification is possible.
- Specimen labelling. Immediately after collection, specimens must be completely and accurately labelled at the patient's bedside.
- In many hospitals computer-generated preprinted labels have replaced handwritten labels. When labelling specimens with preprinted labels, care must be taken to ensure the correct patient label has been attached to the specimen.
- Some hospitals include a final check of labelled specimens prior to leaving the patient's bedside by comparing labelled specimens with the patient's identification band information.
- Specimens must be labelled in the patient's presence.
- Information on the label should include (but not be limited to):
- Patient name, last and first (no initials)
- Patient's ID number (could be healthcare number for outpatients)
- Date of phlebotomy
- The name, initials or computer ID of the phlebotomist, and date and time of collection must also be documented.
For examples of protocols, see:
Role of Patient Records
Whenever a pretransfusion specimen and requisition arrive in the transfusion service, a history check is always done on the patient. Past records can be invaluable in several ways.
2. What are some of the uses of records in the transfusion service?
How to Handle Discrepancies with Records
Whenever current test results disagree with patient records, the transfusion service needs to protect patients in several ways. In this case the ABO blood group done on the patient's current blood sample conflicted with the historical record. The transfusion service immediately set the following in motion:
- Collected a new blood specimen
- Put crossmatched inventory on hold so that it could not be released until the discrepancy was resolved.
- Once the misidentification error had been narrowed to a particular blood collector, instituted a policy of issuing group O Rh negative RBC for urgent transfusions to patients without historical records whose samples had been drawn by the implicated blood collector.
|These policies are used to protect patients because, whenever one misidentified specimen has been drawn, there is a strong likelihood that a second error has also been made.
Each transfusion service sets its own policies in this area. Also, because each case is different, judgement is needed to assess the particulars of each case, particularly regarding which blood to put on hold until the discrepancy is resolved.
4. What could have happened in this case if patient AW did not have an ABO group on record?