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.

Interventions

One of the best practices is to consider where the problems are most likely to occur and institute educational programs to help mitigate the potential occurrence of WBIT instances. For example, in one study the researchers looked at a longitudinal occurrence of WBIT by specialties and found that pediatrics was the most vulnerable (Tinegate, Robertson, & Iqbal, 2013)
Figure 1 - WBIT by Specialty (Tinegate, Robertson, & Iqbal, 2013)

One study provided an intervention among a large-scale group of phlebotomists in Sweden; the intervention was composed of two lectures that addressed the reports of sub-standard VBSC guideline adherence (Bolenius, et al., 2013). The intervention consisted of only two hours so that it did not take away too much time from the workers schedules.

The main finding was that the study demonstrated several significant improvements on phlebotomists' adherence to VBSC practices and compared to the CG we found few significant improvements; however, guideline adherence…