WBIT

WRONG BLOOD IN TUBE

                                                                                              

when a blood sample has not been drawn from the person identified on the sample label, and the laboratory test request form.

In blood banking, these errors are typically identified when the historic blood group of the patient differs from the result of a current sample.  An historical blood group result means the identified patient has previously had a Pre-Transfusion Testing sample (antigen group and antibody screen) sent to Blood Bank and resulted in eTraceline. 

Where no historical result exists, test results will create a new file using the patient identifiers on the tube and form. If a transfusion is required, incompatible blood may be issued by Blood Bank, based on results from the incorrectly identified sample.

WBIT errors may also be identified by clinical areas.  Staff may contact Blood Bank to request a sample not be tested or results withdrawn due to recognised mislabeling soon after sending the sample to the Laboratory.

 These errors can be broken down into three groups:

  1. the intended patient’s blood is in the tube, but the tube and form are labelled with someone else’s details due to an error in sample labelling

  2. the wrong patient was bled but the intended patient’s details are on the tube and form

  3. the intended patient’s blood is in the tube, but the tube and form are labelled with someone else’s details due to the incorrect patient details being attributed to the patient at admission. This error causes delays but does not pose an ABO incompatibility issue for the patient. Because of this, they are better term NHI linking errors than WBITs.

    WBIT errors may be due to

    • not identifying the patient correctly

    • labelling samples away from the bedside, or

    • not immediately after collecting the sample.

    Commonly described risk factors are human factors such as time pressures, competing tasks, stress, interruptions, and fatigue. An alternative approach is to break errors down into mistakes resulting from deliberate noncompliance errors (protocol violations) and/or errors due to cognitive errors attributed to either thinking (knowledge gaps) or execution (slips/lapses). 

    Probabilistically, the blood group of the WBIT sample is coincidentally the same as the intended patient’s. This is termed a “silent WBIT error”. Although these samples do not pose a risk for ABO incompatible transfusion, there remains the risk of a severe transfusion reaction where the intended patient has other red cell antibodies or anomalies that the WBIT sample does not have.

                                                                         

                                                                                                                                                  "wibbit, wibbit"