Wrong blood in tube (WBIT) incidents can occur when blood samples are taken from patients and are either miscollected (blood is taken from the wrong patient but labelled with the correct patient details) or mislabelled (blood is taken from the intended patient but labelled with the incorrect patient details).

Current incident investigations do not always address system-level factors influencing WBIT incidents or seek to understand why blood sampling usually goes right.

Investigation summary

The investigation utilised a safety science approach to consider staff perspectives on blood sampling and labelling practice. The investigation aimed to highlight a range of local and national factors that may contribute to WBIT incidents occurring in acute hospitals.

Reference event

We were informed by an NHS trust of a series of WBIT incidents that had occurred in the Trust’s maternity unit.

The Trust had 16 WBIT incidents in its maternity unit in 2017. In response to this the Trust had rolled out a comprehensive training package for staff. All staff had subsequently been retrained in blood sample collection. However, in 2018 the Trust had a further four WBIT incidents in the maternity unit.

Download and read the full report.

Safety recommendation to NHSX

We’ve made a safety recommendation to NHSX as a result of this healthcare safety investigation:

It is recommended that NHSX should take steps to ensure the adoption and ongoing use of electronic systems for identification, blood sample collection and labelling.

We expect them to respond to their safety recommendation within 90 days of the publication of the investigation report. Their response will be published here when it’s available.

Find out more by reading our report launch news story.