|Year : 2021 | Volume
| Issue : 1 | Page : 22-25
Two sample policy: An effective way to counter wrong blood in tube
Rasika D Setia, Mitu Dogra, Ramesh Yadav
Department of Transfusion Medicine, BLK Superspeciality Hospital, New Delhi, India
|Date of Submission||03-Sep-2020|
|Date of Decision||21-Jan-2021|
|Date of Acceptance||01-Mar-2021|
|Date of Web Publication||29-May-2021|
Dr. Mitu Dogra
Department of Transfusion Medicine, BLK Superspeciality Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Background and Objectives: Pretransfusion testing has undergone remarkable changes over the past few decades starting from manual methods to semi-automation to full automation, but sample collection from the right person is out of scope of blood center. Through this study, we tried to address this issue by introducing two-sample policy in our institute. The objective of this study is to emphasize the importance of using two different samples for type and screen and crossmatch. Methods: This is a retrospective study extending over a period of 3.5 years (January 2015–June 2018) in a tertiary care health center. Retrospective data collections were done for the period post implementation of two-sample policy in the institute. As per the two-sample policy, two samples of the same patient would be collected, one at the time of type and screen and other at the time of blood component arrangement request. In case of any discordance between the two samples, incident is generated. Results: Of total 110,949 requests, 85,326 blood/blood components were issued, 56879 of which were for packed red blood cells (PRBCs) and a total of 34,922 PRBC units were released in the study duration. A total of 22/(0.06%) errors were recorded as grouping discrepancy between type and screen sample and sample received for blood component arrangement request. Incidentally, all 22 cases were for the arrangement of PRBC. Out of 22 errors, 20 were near misses and were detected in immunohematology laboratory at the time of compatibility testing and 2/22 (9.09%) errors were actual no harm events. Conclusion: The problem of wrong blood in tube (WBIT) is still a challenge faced by many laboratory persons. The issue can be resolved by training dedicated staff for sample collection. Although this policy has many drawbacks, such as added costs of sample collection and double testing, inconvenience to the patient, delay in providing blood, and increased type O blood use, we would like to emphasize that it would be helpful in error reduction.
Keywords: Wrong blood in tube, packed red cell, Intensive care unit
|How to cite this article:|
Setia RD, Dogra M, Yadav R. Two sample policy: An effective way to counter wrong blood in tube. Glob J Transfus Med 2021;6:22-5
| Introduction|| |
Over the past several decades, there has been a major focus on improving blood safety through quality management systems. Many steps have been taken to reduce incidence of transfusion transmitted infections by use of more and more sensitive techniques. Infections from blood transfusion have become increasingly rare; however, the problem of ABO-incompatible red blood cell (RBC) transfusion still remains a major threat.
In majority of cases, laboratory personnel are not directly involved in sample collection process and are largely dependent on others for the collection of blood sample, correct patient identification, and appropriate labeling of the sample. Adopting type and screen policy definitely helps in reducing turn-around-time, but whether a sample is from the correct patient or not is still a big challenge. Keeping this in mind, we have introduced two-sample policy at our hospital, which means one sample is collected for type and screen and another sample collected at different times by different phlebotomists for crossmatching with their signature, ID no., and time of sample collection. Both should be received at different points of time in a blood bank.
Aims and objectives
In this study, we have tried to highlight the importance of two sample policy to avert major/critical transfusion-related adverse events.
| Materials and Methods|| |
This is a retrospective study extending over a period of 3.5 years (January 2015–June 2018) in a tertiary care health center. Retrospective data collections were done for the period postimplementation of two-sample policy in the institute. As per the policy for any patient requiring blood transfusion, two samples of the same patient would be collected, one at the time of type and screen and the other at the time of blood request, each sample bearing the signatures of phlebotomists. The sample label would bear the patient's name and unique registration number as per the hospital policy. In case of any discordance, the sample would be rejected Blood group done on the second sample would be compared with that of the first sample done previously using the hospital information system in the blood bank. Any discrepancy in blood group, if found, would be thoroughly investigated and a third blood sample would be requested to confirm the blood group. In emergency situations, in the interim period, O negative packed red blood cell (PRBC) would be arranged for the patients; however, the process of sample confirmation would be completed. In life-threatening emergencies, collection of the second sample would be exempted. In case of wrong blood in tube (WBIT) or any other discrepancy, an incident report was generated. Only cases where type and screen samples were followed by second crossmatch samples were included in the study.
The following definitions were used while reporting an incident:
- An error: Defined as any deviation from established policies and standard operating procedures
- A near-miss event: Defined as an error, which did not reach the patient
- An actual harmful event: Defined as an error, the effect of which reached the patient and caused harm
- Actual no-harm event: An event, which reached the patient but caused no harmful event.
Errors were also categorized according to the location from where the sample was sent and time of occurrence. Two work shifts were decided for study purposes and were classified as day shift (8 am–5 pm) and night shift (5 pm–8 am).
Errors were also categorized according to the type of discrepancy where
- Major discrepancy: Major ABO incompatibility, for example, from type A, B, AB blood group to O blood group
- Minor discrepancy: Minor ABO incompatibility, for example, from type O blood group to A, B, AB blood group
- Bidirectional: For example, from type A blood group to B blood group, vice versa.
The institutional ethical clearance was obtained from Institutional Ethics Committee. As a blood transfusion policy of hospital, patients give informed consent prior to every blood transfusion and that is valid for 24 hours. In view of the retrospective observational study design and no risk of disclosure of patient identity, consent to review the records was waived off. Confidentiality of data was maintained at all times.
| Results|| |
A total of 110,949 requests were received for different blood components during the study period. Among these, 56,879 requests were received for PRBC, 31,554 requests were received for random donor/single-donor platelets, and 22,516 requests were received for fresh frozen plasma/cryoprecipitate. Of a total of 110,949 requests, 85,326 blood/blood components were issued, 56,879 of which were for PRBCs and a total of 34,922 PRBC units were released in the study duration.
[Table 1], [Table 2] and [Table 3] show the distribution of error that is wrong sample in tube according to the location of origin, shift of origin and type of discrepancy respectively.
A total of 22/(0.06%) errors were recorded as grouping discrepancy between type and screen sample and sample received for crossmatch request [Table 4]. Incidentally, all 22 cases were for the arrangement of PRBC. Of the 22 errors, 20 were near misses and were detected in immunohematology laboratory at the time of compatibility testing and 2/22 (9.09%) errors were actual no harm events [Table 5]. [Table 6] shows categorization of errors and its percentage. [Table 7] shows statistical analysis based on location.
Chi-square goodness of fit test to find out the error distribution at different locations was applied.
| Discussion|| |
One of the most critical steps of blood component transfusion is blood sampling for pretransfusion testing, which can lead to the catastrophic event of intravascular hemolysis due to ABO incompatibility in case of errors. Mismatched blood transfusion with ABO-incompatible blood poses a threefold greater risk for transfusion recipients than the risk of transmission of transfusion-transmitted infectious disease, accounting for 37% of all reported transfusion-associated reactions in the United States. According to Serious Hazards of Transfusion (SHOT), the most serious of all reactions are ABO-incompatible red cell transfusions, resulting in death or major morbidity. SHOT (1996–2010) reported 386 cases of WBIT as being the major cause of near misses. Various national hemovigilance programs also document that transfusion of blood of the incorrect type remains a significant problem in transfusion safety., National Haemovigilance Programme of India reported 3903 transfusion reactions, of which 22 (0.56%) were due to ABO mismatch despite precautions and standard operating procedures being in place. As samples are often shared across laboratories, wrong sample in tube (WBIT) can also lead to wrong reporting of other critical tests run in microbiology, hematology, and biochemistry laboratories. Sample collection error was the most common error detected by Maskens et al. Events related to sample collection such as unlabeled or mislabeled samples were the most common errors, constituting 35.5% of all the errors as reported by Sidhu et al. In the 2011 annual report from SHOT, there were 247 incorrect blood components transfused. In our study, we identified 22 (0.06%) errors out of 34,922 PRBC units issued and frequency of near misses was 5.7/10,000 transfusions. Of 22 errors 6 (27%) errors were classified under major discrepancy having the potential to cause transfusion of ABO-incompatible blood component. Majority of the errors were reported from the wards followed by intensive care unit and emergency and none from operation theaters (OTs). No reporting of errors from OTs could possibly owing to the fact that each OT has only one patient, thus possibility of sample mix-up being almost rare. After relooking into error distribution according to shifts, surprisingly we recorded more errors during day shift as compared to night shift. This could also be attributed to the fact that more number of blood requests are generated during day hours and major blood transfusions are also administered during the daytime. We may have missed silent WBIT errors that occur when the ABO group of the blood in tube matches the ABO group of the correct patient although the wrong patient's blood is collected. It would be no exaggeration if it is said that even after having quality assurance programs and accreditations in place, basic attitude problems of the staff/phlebotomists are still the major obstacle that we all need to overcome to reduce this menace. Practices that may contribute to frequent WBIT include labeling of sample tubes away from bedside, failure to check patient identity, and the use of preprinted labels. Such practices can only be stopped by repeated training and competency assessment of phlebotomists. In such circumstances, two-sample policy can really help if followed flawlessly. The British Committee for Standards in Hematology recommended that whenever possible a second blood sample should always be obtained to confirm the blood group and check for ABO compatibility before arranging/issuing red cells for a patient. This practice reduces the possibility of issuing ABO-incompatible blood to a patient which may arise due to preanalytical error owing to mislabeling of blood sample collected for type and screen.
Limitations of the study
The requirement for a second sample was foregone at the time of life-threatening emergencies to expedite the issue of blood.
| Conclusion|| |
Use of two-sample policy can help to alleviate errors in transfusion. It is therefore important for centers to have a policy in place to collect two different samples – one for type and screen and another for crossmatch meticulously for improved recipient haemovigilance.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]