Educational Case
Educational Case: Wrong Blood in Tube
Academic Pathology Volume 4: 1–2 ª The Author(s) 2017 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2374289517708310 journals.sagepub.com/home/apc
Joan Uehlinger, MD1
The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/ doi/10.1177/2374289517715040. Keywords pathology competencies, preanalytic error, wrong blood in tube, quality improvement, process control, specimen identification, diagnostic medicine, therapeutic pathology Received February 17, 2017. Received revised April 6, 2017. Accepted for publication April 13, 2017.
Primary Objective Objective GP1.1: Pre- and Postanalytical Errors. Give examples of common sources of preanalytical and postanalytical errors and categorize errors when the following procedures are not properly followed: pairing patient/specimen identification with the requisition forms, using correct specimen containers/tubes for specific tests, and timing of collection, transport, and storage. Competency 3: Diagnostic Medicine and Therapeutic Pathology; Topic GP: General Principles; Learning Goal 1: Laboratory Tests.
Patient Presentation A 35-year-old woman is scheduled for a tubal ligation, and a preoperative type and screen is sent. She had never been transfused at this facility. A type and screen was drawn 6 months ago and showed that she was A positive with a negative antibody screen.
Diagnostic Findings, Part 1 Results from the current type and screen revealed the sample was O positive with a negative antibody screen.
blood products in all steps from donation of blood to testing of blood products to transfusion of blood products. Standards specifically indicate that “identifying information for the patient and the sample shall correspond and be confirmed at the time of collection using two independent identifiers.”1,2 Another standard says that “the transfusion service shall confirm that all identifying information on the request is in agreement with that on the sample.”1,2 The purpose of using 2 identifiers is to ensure that the blood sample is from the correct patient, and should that patient need blood products, the correct blood products can then be issued.
Review the patient history The history review is a required step in sample processing. The standards indicate that “there shall be a process to ensure that the historic records for the following have been reviewed . . . ABO group and Rh type. . . . These records shall be compared to current results, and any discrepancies shall be investigated and appropriate action taken . . . .”2,3 The purpose 1
Questions/Discussion Points, Part 1 What Are the First Steps Taken Upon Sample Receipt? Check that the sample is labeled with 2 identifiers. AABB publishes standards that are required to ensure the safety of
Montefiore Medical Center and The Albert Einstein College of Medicine, Bronx, NY, USA
Corresponding Author: Joan Uehlinger, MD, Montefiore Medical Center and The Albert Einstein College of Medicine, 111 East 210th Street, Bronx, New York, NY 10467, USA. Email: [email protected]
Creative Commons CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
2
Academic Pathology
of reviewing the historic records is to help ensure that if there is an accidental mislabeling of a patient sample, it will be identified before any blood products are administered to the patient.
Diagnostic Findings, Part 3
What Possible Explanations Should Be Considered?
Questions/Discussion Points, Part 3
Except in 1 particular circumstance, the blood type of a patient should not change. There are a limited number of possible explanations for the current findings. The current sample could be from the wrong patient. The sample taken 6 months ago could have been from the wrong patient. Or, if the patient had a stem cell transplant in the interval from a type O allogeneic donor, her blood type could have changed.
What should be done in follow-up of this event?
What Should the First Steps Be to Determine the Etiology of the Problem? There are 2 very important steps that need to be completed to investigate a possible mislabeling of a blood sample. The first is to get the history to be sure the patient did not have a transplant, and in addition to ask for another sample to be drawn from the patient to see whether it matches the historical data or the data from the current blood sample.
Diagnostic Findings, Part 2 Evaluation reveals that the patient has not had a stem cell transplant. A second sample is sent for evaluation which is determined to be A positive, negative antibody screen.
A second patient was not found.
Follow-up regarding process control, patient identification, and labeling should be done. This should include a review of the training and competency of any involved health-care professionals, which may reveal the need for additional training.
Teaching Points Patient identification is critical to patient safety and diagnostic accuracy. Possible patient identification errors must be investigated fully and promptly, as more than 1 patient may be involved. Reducing errors requires strict adherence to clinical procedures. In this example, samples must be labeled with 2 identifiers in the presence of the patient. All identifying information on the request must be in agreement with the sample label. The history review is a required step in specimen processing.
Questions/Discussion Points, Part 2 What Are Your Conclusions?
References
The sample drawn earlier that day was from the wrong patient. The phlebotomy area should be alerted as there may be another incorrect sample if this was a single direct switch of identifiers on the tube (another patient who is really an O may have been typed as an A). For patients that are hospitalized, it is just as important to evaluate where the blood sample came from and investigate if there could be an accidental mislabeling of samples.
1. College of American Pathologists Accreditation Program. Transfusion Medicine Checklist, Standards TRM 40235 and TRM 40250. 2. AABB. Standards for Blood Banks and Transfusion Services. 30th ed. Bethesda MD: AABB; 2016:34-35, 37. 3. AABB. AABB Technical Manual. 18th ed. Bethesda MD: AABB; 2014:368-369.
Educational Case: Wrong Blood in Tube
Academic Pathology Volume 4: 1–2 ª The Author(s) 2017 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2374289517708310 journals.sagepub.com/home/apc
Joan Uehlinger, MD1
The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/ doi/10.1177/2374289517715040. Keywords pathology competencies, preanalytic error, wrong blood in tube, quality improvement, process control, specimen identification, diagnostic medicine, therapeutic pathology Received February 17, 2017. Received revised April 6, 2017. Accepted for publication April 13, 2017.
Primary Objective Objective GP1.1: Pre- and Postanalytical Errors. Give examples of common sources of preanalytical and postanalytical errors and categorize errors when the following procedures are not properly followed: pairing patient/specimen identification with the requisition forms, using correct specimen containers/tubes for specific tests, and timing of collection, transport, and storage. Competency 3: Diagnostic Medicine and Therapeutic Pathology; Topic GP: General Principles; Learning Goal 1: Laboratory Tests.
Patient Presentation A 35-year-old woman is scheduled for a tubal ligation, and a preoperative type and screen is sent. She had never been transfused at this facility. A type and screen was drawn 6 months ago and showed that she was A positive with a negative antibody screen.
Diagnostic Findings, Part 1 Results from the current type and screen revealed the sample was O positive with a negative antibody screen.
blood products in all steps from donation of blood to testing of blood products to transfusion of blood products. Standards specifically indicate that “identifying information for the patient and the sample shall correspond and be confirmed at the time of collection using two independent identifiers.”1,2 Another standard says that “the transfusion service shall confirm that all identifying information on the request is in agreement with that on the sample.”1,2 The purpose of using 2 identifiers is to ensure that the blood sample is from the correct patient, and should that patient need blood products, the correct blood products can then be issued.
Review the patient history The history review is a required step in sample processing. The standards indicate that “there shall be a process to ensure that the historic records for the following have been reviewed . . . ABO group and Rh type. . . . These records shall be compared to current results, and any discrepancies shall be investigated and appropriate action taken . . . .”2,3 The purpose 1
Questions/Discussion Points, Part 1 What Are the First Steps Taken Upon Sample Receipt? Check that the sample is labeled with 2 identifiers. AABB publishes standards that are required to ensure the safety of
Montefiore Medical Center and The Albert Einstein College of Medicine, Bronx, NY, USA
Corresponding Author: Joan Uehlinger, MD, Montefiore Medical Center and The Albert Einstein College of Medicine, 111 East 210th Street, Bronx, New York, NY 10467, USA. Email: [email protected]
Creative Commons CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
2
Academic Pathology
of reviewing the historic records is to help ensure that if there is an accidental mislabeling of a patient sample, it will be identified before any blood products are administered to the patient.
Diagnostic Findings, Part 3
What Possible Explanations Should Be Considered?
Questions/Discussion Points, Part 3
Except in 1 particular circumstance, the blood type of a patient should not change. There are a limited number of possible explanations for the current findings. The current sample could be from the wrong patient. The sample taken 6 months ago could have been from the wrong patient. Or, if the patient had a stem cell transplant in the interval from a type O allogeneic donor, her blood type could have changed.
What should be done in follow-up of this event?
What Should the First Steps Be to Determine the Etiology of the Problem? There are 2 very important steps that need to be completed to investigate a possible mislabeling of a blood sample. The first is to get the history to be sure the patient did not have a transplant, and in addition to ask for another sample to be drawn from the patient to see whether it matches the historical data or the data from the current blood sample.
Diagnostic Findings, Part 2 Evaluation reveals that the patient has not had a stem cell transplant. A second sample is sent for evaluation which is determined to be A positive, negative antibody screen.
A second patient was not found.
Follow-up regarding process control, patient identification, and labeling should be done. This should include a review of the training and competency of any involved health-care professionals, which may reveal the need for additional training.
Teaching Points Patient identification is critical to patient safety and diagnostic accuracy. Possible patient identification errors must be investigated fully and promptly, as more than 1 patient may be involved. Reducing errors requires strict adherence to clinical procedures. In this example, samples must be labeled with 2 identifiers in the presence of the patient. All identifying information on the request must be in agreement with the sample label. The history review is a required step in specimen processing.
Questions/Discussion Points, Part 2 What Are Your Conclusions?
References
The sample drawn earlier that day was from the wrong patient. The phlebotomy area should be alerted as there may be another incorrect sample if this was a single direct switch of identifiers on the tube (another patient who is really an O may have been typed as an A). For patients that are hospitalized, it is just as important to evaluate where the blood sample came from and investigate if there could be an accidental mislabeling of samples.
1. College of American Pathologists Accreditation Program. Transfusion Medicine Checklist, Standards TRM 40235 and TRM 40250. 2. AABB. Standards for Blood Banks and Transfusion Services. 30th ed. Bethesda MD: AABB; 2016:34-35, 37. 3. AABB. AABB Technical Manual. 18th ed. Bethesda MD: AABB; 2014:368-369.
