Notification of investigation

The HSIB was notified of an incident where a patient’s blood sample was incorrectly labelled with another patient’s details. HSIB has launched an investigation regarding incorrect patient details being recorded on blood samples. 

The investigation will focus on providing a Safety II approach to consider staff perspectives on blood sampling and labelling practice. Safety II considers how performance is adapted to respond to varying conditions and how these adaptations represent not only how things go wrong, but also how things usually go right. 

The investigation will also highlight the human factors considerations and inherent risks in blood sampling and labelling practice presented to staff in acute hospital settings.

Please contact enquiries@hsib.org.uk to register for email updates on this investigation.

Contact us to receive updates

If you would like information about a particular investigation please let us know

Contact us to receive updates