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.

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.

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.

Download and read the full report.

Safety recommendation

We made one safety recommendation to NHSX as a result of this healthcare safety investigation. 


Safety recommendation

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.


The ambition of NHSX is for every NHS trust to use digital systems to maximise the quality and safety of care. This requirement clearly includes having safe systems in place for the identification, labelling and tracking of blood samples.

We will ensure that the need to have such systems in place is communicated to all trusts as part of our work on defining good practice in digital transformation. A number of blueprints developed through our GDE [Global Digital Exemplars] and Fast Follower programme set out how this can best be achieved. We will make sure they are available to all trusts as an effective means of sharing best practice on the issue.

This response was received on 14 January 2020.


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