Wrong Blood in Tube ErrorsLegal Issues and Recommendations

Angeli Lagasca, RN, BSN, CCRNColumbia University, Teachers CollegeDecember 5, 2014

CASE STUDY

DISCUSSION:

What went wrong in this scenario?

What were some contributing factors?

Were there opportunities to prevent these events?

WHAT IS A WBIT?

W.B.I.T.- WRONG BLOOD IN TUBE- Blood is drawn from Patient A- Sample is labeled with Patient B’s information

WHAT HAPPENS NEXT?

“Near-miss”- Error is caught immediately- No harm is caused to either patient

Unnecessary Treatment- Pt B’s label is used on Pt A’s specimen- Pt B is treated for Pt A’s results

Delayed/Missed Treatment

- Pt A’s irregular results logged as Pt B’s- Pt A is not treated for these results

WHAT’S THE WORST THAT COULD HAPPEN?

INCOMPATIBLE BLOOD TRANSFUSION- Type & screen or cross-match is performed with Pt A’s blood- Testing is logged under Pt B’s lab results- Pt B is transfused with blood which has not been properly matched

=HEMOLYTIC REACTION: SEVERE INJURY, DEATH

CIRCUMSTANCES OF OCCURRENCE

BLOOD SPECIMEN COLLECTION ERROR OCCURS WHEN:

“...Tubes are labeled away from the bedside...the patient's identity is not checked before drawing the blood ...and with the use of preprinted labels"

(AULBACH ET AL., 2010 p. 48)

RISK FACTORS

WBITHUMAN ERRORSYSTEMS ERROR

POOR P&PINADEQUATE EDUCATION

SYSTEMS / EQUIPMENT ISSUESLACK OF SUPPORT FOR STAFF

ANXIETYFATIGUESTRESSFUL SITUATIONSDISTRACTIONSUNFAMILIARITY WITH TASK

LEGAL ISSUES: BREACH OF DUTY?

INDIVIDUAL NONCOMPLIANT WITH P&P?DID NOT MEET STANDARD OF CARE?FAILED TO ASSESS/MONITOR?NO ESCALATION OF CONCERNS?DID NOT ADVOCATE FOR PT SAFETY?

ORGANIZATION RESPONDEAT SUPERIORINADEQUATE P&P?SYSTEMS DID NOT ALLOW FOR COMPLIANCE?POOR RISK MANAGEMENT/QI INVOLVEMENT?

PREVENTION: RISK MANAGEMENT

COLLECT INFORMATIONIncident reporting, chart, interview

I.D. CAUSES, CONTRIBUTING FACTORSIndividual and/or systems errors

ADDRESS AREAS OF VULNERABILITYAdaptive P&P, equipment, education

EVALUATE EFFICACYMeasure compliance, rate of error

PREVENTION: POLICIES

SPECIMEN COLLECTION- Verify patient identity- Match ID band to specimen labels- Affix labels at the bedside

PRETRANSFUSION- Two separate blood samples- Two witnesses at sample collection- Verify identity, affix labels at bedside

IMPLICATIONS: NURSING EDUCATION

ACADEMIC SETTINGS:- PATIENT IDENTIFICATION- PATIENT SAFETY- STANDARD OF CARE

PRACTICE SETTINGS:- CHANGES TO POLICY- OBSERVATION/REMEDIATION

COMMUNICATION!

IN CONCLUSION...

WBIT ERROR IS CAUSED BYA DRIFT FROM THE BASICS:PATIENT IDENTIFICATION!As Nurse Leaders, we can advocatefor patient safety by providingcommunication and supportfor nurses.

QUESTIONS?

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