Photo by Renjith KrishnanSyndicated from Impacted Nurse Tue, 12/14/2010
One of the more serious mistakes we can make as nurses, is to incorrectly identify a blood specimen we are sending off to pathology.
This is known as ‘Wrong Blood in Tube’ or WBIT, and can result in incorrect treatment being given to a patient based on their ‘wrong’ pathology results or even more seriously, a wrong blood transfusion being administered. Mistransfusion error is a leading cause of serious morbidity and mortality from blood transfusions.
It is estimated that WBIT occurs at a rate of around 1 in 2000 samples taken. Incorrectly identifying the patient and mislabelling the pathology tubes account for up to 15% of such errors. However, the actual number is thought to be much higher than this as many of these types of errors are ‘discovered’ prior to the specimen being sent and therefore not reported (as a near miss).
Some of the poor practices that can lead to WBIT include:
•Labelling of sample tubes away from the patients bedside.
•Failure to correctly confirm the patients identity.
•Patients with similar or identical names that have not been flagged.
•Use of pre-printed labels
•Inaccurate verbal instructions.
The Victorian Managed Insurance Authority has published an excellent manual: Reducing Harm in Blood Transfusions Investigating the Human Factors behind ‘Wrong Blood in Tube’ (WBIT) events in the Emergency Department.
Some of the factors that spoil our ability to follow best practice in specimen labelling include:
•High number of patients (with pressure on turnover)
•Urgency of individual cases.
•Ability of patients to communicate.
•Low staff to patient ratios.
•Time pressures.
•High workloads
•High stress (emotional demands of work)
•Interruptions.
•Rotating staff (implications on education and team culture)
•Fatigue (physical and mental pressures)
The ED is an environment where patient volume is high and requires that individual patients are processed quickly and efficiently. This can cause stress for staff, particularly when patients are very sick and the timeliness of appropriate treatment has the potential to impact on patient outcomes. In addition, the high physical and cognitive workload involved in long shifts can compound the stress with fatigue effects. Overnight and weekend shifts, with limited ‘back-up’, were reported in the interviews to be associated with more errors. Sometimes blood tubes were sent completely unlabelled. The unevenness of patient volume on these shifts can also place great demands on a ‘skeleton’ staff. Lack of staff redundancy results in an inability to relieve pressure when patient volume is high.
Correct ID
The study found that on many occasions nurses do not accurately identify their patients. Sometimes patient ID bracelets have not been applied or have incorrect information.
Commonly nurses asked the patient to simply confirm the information on their ID bracelet rather asking the patient to state their family name, given name and DOB whilst the nurse checks this information against the bracelet and the pathology documentation (as is best practice).
And doctors were found to be worse than nurses.
Interruptions
Nurses were observed to be commonly interrupted (by doctors or other nursing staff). Such interruptions and multi-tasking have recently been reported as a major cause of clinical inefficiency and error in Australian hospitals.
Fatigue
Fatigue is a huge issue with staff working in our emergency departments.
Fatigue affects performance by impairing; concentration, judgement, decision-making, memory function and physical coordination. It results in increased error rates and lower efficiency. All of these are threats to patient safety.
Despite these effects being well known, hospital culture often requires people to work even when identifiably fatigued. More to the point, with increasing patient throughput and demand on the health system, the luxury of being able to stop work when fatigued is generally not a viable one.
The report recommends the ideal process in a simplified form, in order to prevent WBIT error is:
1. Ensure request form is completed with all patient identifiers required i.e. full name, UR Number, and/or DOB.
2. Assemble all equipment required to collect the specimen, including sufficient patient labels (if these are used) to label specimens.
3. Identify patient using positive ID process: ask the patient to state full name and DOB and
check these details and UR Number against ID band, patient documents and/or any products.
4. Collect specimens and place into appropriate containers using appropriate technique.
5. After checking UR labels, match the patient identifiers on request form and wrist band, label each specimen and initial that each label was checked for correct patient details. Sign and note date and time on request form.
6. Place all specimens in biohazard bag and seal, placing request form in outside pocket.
7. Dispatch to pathology laboratory.
