Our latest report highlights that mislabelling of blood samples could pose a deadly risk to patients.

The reference event in the report is a case where patient details became mixed up on blood samples sent from a maternity unit. In the case of mislabelling on blood transfusion samples, the impact could be devastating. There’s the potential for serious injuries and even death. But, even the delay in care resulting from wrong blood test results could cause significant psychological distress to patients.

Wrong blood in tube

National data from SHOT (Serious Hazards of Transfusion) indicates there were 792 ‘wrong blood in tube’ near misses (where the error was spotted in time and no patient suffered harm) relating to blood transfusion samples, in 2018 across England. This doesn’t account for blood samples taken for any other purpose.

Our investigation showed why these incidents happen and most importantly what can be done to reduce the risk of it happening again. The investigation looked at all the factors involved and found evidence to show that electronic systems could help staff in busy environments, by making the processes easier and more efficient, to manage and reduce the risk to patients.

Expert view

Dr Stephen Drage, HSIB Director of Investigations and ICU consultant, said: “Millions of blood tests are carried out across the NHS each year, from GP surgeries to large teaching hospitals. Most happen without incident but when it does go wrong it could represent a catastrophic outcome for patients, families and staff.

“It was paramount in this investigation that we understood how clinical staff work in practice with blood sampling and labelling and how this might differ from how it’s perceived by policymakers. By taking this approach, we can recommend the most effective improvements that will play a crucial role in stopping this happening time and time again.”

Dr Paula Bolton-Maggs, Consultant Haematologist and former Medical Director of the SHOT haemovigilance scheme, comments: “This report of a ‘near miss’ blood sample incident has wide applicability. Individuals work in teams in healthcare, but vulnerability to error is increased by short staffing and long shifts. Correct patient identification is crucial. Biological samples and their results, if attributed to the wrong patient, can lead to disastrous outcomes including fatal ABO-incompatible transfusions or other serious treatment errors.

“It is good to see endorsement of vein-to-vein electronic patient identification systems (as recommended by SHOT for transfusion), and increased recognition for training in 'human factors'.”

Read the report

For more information, including the safety recommendation in full, download and read the ‘wrong patient details on blood sample’ report.