Wrong Blood in Tube
In a hospital environment, it can sometimes be difficult to pay attention to detail with many tasks. However, it is often the case that paying close attention to detail can save lives in many instances. Blood in the wrong tube (WBIT) can occur when a blood specimen is taken from a patient and labeled incorrectly for a variety of reasons. Blood can be taken from the wrong patient and mislabel or the blood from the correct patient can be also labeled with the wrong patient information. When this happens a patient can be given the wrong pathology results and may receive the wrong treatment which can significantly reduce health outcomes.
Within 35 days within the Orange County Hospital has experienced 11 WBIT specimens. The accompanying investigation of each WBIT has uncovered a wide spread problem within the institution. There was mostly likely user error in these processes however the hospital also blames the collection practice in its entirety. The process should be redesigned to address the following problems:
• Labeling of specimens away from the patient's bedside.
• Failure to correctly use patient identifiers
• Patients with similar, or identical names that have not been flagged.
• Use of pre-printed labels from previous patients.
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