Introduction: Wrong blood in tube (WBIT) events are defined as blood specimens in containers labeled with another patient’s information. These events present a substantial risk to the patient, as transfusion of an ABO incompatible product can result in significant patient harm or death. Despite interventions aimed at decreasing WBIT events such as dual-nurse signoff of patient identification and enhanced education, these events persist. Passwater et. al. (2022) reported that manual patient identification of blood samples led to a WBIT error rate of 0.61%, while electronic identification of the patient yielded an error rate of 0.045%. Stakeholders at an academic, community Magnet®-designated hospital identified an opportunity to modify the existing workflow to reduce the incidence of WBIT events, thus decreasing the risk to patients. This presentation summarizes the strategies used to implement an organizational change in practice affecting bedside clinicians, blood bank technicians, and technology stakeholders.

Methods/approach: The clinical informaticist led the effort to complete a comprehensive workflow evaluation, including a survey of bedside nursing clinicians, to best identify challenges in the current confirmatory specimen collection process. This information was synthesized for themes and presented to operational and technology stakeholders. The clinical informaticist assisted in breaking down legacy barriers for ordering the confirmatory specimen, identified access requirements for lab colleagues, and provided education to bedside clinicians.

One such barrier was the lack of a confirmatory specimen order in the electronic health record (EHR), when all other specimen orders were available in the EHR to print specimen labels at the bedside. While blood bank technicians were the personnel who identified if a patient required a confirmatory specimen, they did not have access to the EHR. The workflow was redesigned to allow confirmatory specimen orders to be placed in the EHR by blood bank technicians and cosigned by the transfusionist. This allowed for the specimen label to be printed at the bedside by collecting clinicians and leveraged barcode scanning of both the patient wristband and specimen container at the time of collection.

Results: Post-intervention, WBIT events were decreased from an average of 3.75 occurrences per month to an average of 2.5 occurrences per month. This was calculated by evaluating WBIT events reported in the 12 months pre- and post-intervention. Improved compliance with the workflow was also noted, evidenced by the decrease in number of confirmatory specimens that went uncollected when comparing data from six months pre-intervention to six months post-intervention.

Implications for practice: Clinical informatics was instrumental in pushing through barriers to enhance patient safety after evaluating multiple interventions to improve practice. By keeping patient safety at the center of the conversation, the team was able to collaborate to identify a solution that has positively impacted patient care. Information gained during this presentation can be incorporated within a variety of settings to improve collaboration between operational and technology stakeholders to improve patient care through safe ABO collection processes. This work also emphasizes the benefit of technology applications at the bedside to enhance patient safety.

Amy Taff MSN, RN, NI-BC

Appearances