Patient Blood Management
Wrong Blood in Tube (WBIT)
Wrong Blood in Tube is an error that occurs where identification information (label and request form) belong to one patient but
the blood in the tube belongs to another patient.
In HNE Health, this error is identified approximately 7-8 times each year, in pre-transfusion testing samples. It is known that
this represents only 50% of the actual errors occurring, and that many such errors are occurring in samples collected for
non-transfusion tests. The error is only identified if the patient has a previous blood group record, and the blood being tested is
not the same group as the previous record. Many episodes are unable to be detected.
Serious Consequences of WBIT: The worst case is patient death, from an ABO group incompatible Blood
Transfusion. Other serious harm can result from incompatible blood transfusion due to other blood group antibodies, not
present in the tested sample, and missed administration of Rh(D)Prophylaxis to pregnant Rh(D) Negative women. Even in
non-transfusion samples, WBIT can result in poor decisions regarding patient health, medications, infection, and poor
decisions regarding discharge or admission to hospital as the results examined do not relate to that patient.
How can WBIT be prevented? All staff collecting blood must have completed the BloodSafe e-Learning
Clinical Transfusion Practice training. The request form must be completed prior to collecting the blood, and is part of the
identification checks at the patient’s side. The patient must be asked to state their name and date of birth, or be identified
in the presence of a witness by checking their identification band against the request form. The samples must be
labelled at the patient’s side, prior to moving away from the patient. The witness, or patient must sign the request form
confirming the details are correct on the sample and the request form.
Contact the HNE LHD Patient Blood Management Officer: Vicki.Martens@hnehealth.nsw.gov.au
WBIT is a SAC 2 IIMS:
Usually the Pathology Laboratory will identify when WBIT has occurred in a pre-transfusion testing sample,
and Laboratory staff have been requested to enter these events into IIMS as SAC 2.
From 2015, all WBIT incidents in HNE Health are required to undergo London Protocol investigations. The potential for
catastrophic patient outcome is so high for these incidents that our organisation has agreed to undertake a thorough
systematic review of each individual incident.
A guide to assist the investigation of these events has been developed. If you are the manager of an area where a WBIT
incident has been identified please contact the HNELHD Patient Blood Management Officer or your Local PSO who will help
to guide you through the London Protocol process.
NBA Guidelines Link: http://blood.gov.au/pbm-guidelines
Mistaken Identity Matters!