Addressing sample identification errors in a multispecialty tertiary care hospital in Bangalore

Abstract

Errors in sample identification contribute to patient mismanagement and erroneous administration of blood and blood products. This report describes the rate of sample identification errors over 2 years in a multispecialty hospital in India and possible measures to decrease these errors. Various measures were taken to reduce the risk of identification errors during sample collection, laboratory processing and administration of blood. The bedside blood grouping method by the slide agglutination technique was also introduced along with other measures in December 2011 as a risk mitigation step to prevent an ABO incompatible transfusion, as well as to provide a method of surveillance for possible errors during transfusion. The rate of sample identification errors was 48 and 45 per 1,000,000 among the total tests billed in 2011 and 2012, respectively. In the blood bank alone, the sample identification error rate was 0·96 in 2011 and 0·46 in 2012 per 1000 bags of blood and blood components issued after the various steps to prevent such errors in the blood bank were introduced. 81% of these errors (26 out of 32) have been reported in the inpatient setting. 15·6% (5 out of 32) were repeat errors made by the same technicians. Among the various measures used to reduce sample identification errors, bedside blood grouping allows prevention of ABO incompatible transfusions when performed by trained technicians and may also be used as a method of active surveillance for sample identification errors in hospitals.