Dzik W H, Murphy M F, Andreu G, Heddle N, Hogman C, Kekomaki R, Murphy S, Shimizu M, Smit-Sibinga C T
Blood Transfusion Service, Massachusetts General Hospital, Boston 02114, USA.
Vox Sang. 2003 Jul;85(1):40-7. doi: 10.1046/j.1423-0410.2003.00313.x.
Collection of a blood sample from the correct patient is the first step in the process of safe transfusion. The aim of this international collaborative study was to assess the frequency of mislabelled and miscollected samples drawn for blood grouping.
Hospitals in 10 countries provided data on sample error rates during a period of at least 3 months, including the last quarter of 2001. Mislabelled samples were defined as those not meeting local criteria for acceptance by the laboratory. Miscollected samples [wrong-blood-in-tube (WBIT)] were defined as samples in which the blood group result differed from the result on file from prior testing. WBIT rates were corrected for the proportion of repeat samples and for undetectable errors occurring as a result of chance collection of blood from the wrong patient with the same ABO group. Participants also completed a questionnaire on current policies regarding sample collection.
A total of 71 hospitals completed surveys describing policies related to sample collection. Sixty-two hospitals provided usable data on the frequency of mislabelled and miscollected samples. Mislabelled and miscollected samples were common. Based on results from over 690,000 samples, the median hospital performance resulted in a rate for mislabelling of 1 in every 165 samples (6.1 per 1000; interquartile range 1.2-17 per 1000). The presence of national patient identification systems in Sweden and Finland was associated with rates of miscollected samples that were too low to estimate. Outside these nations, miscollected samples demonstrating WBIT occurred at a median rate of 1 in every 1986 samples (0.5 per 1000; interquartile range <0.3-0.9 per 1000). There was great variation worldwide in the reported frequency of mislabelled samples, probably resulting from variation in policies for sample acceptance. Miscollected samples occurred at a more constant rate.
The rate of mislabelled samples and miscollected samples is 1000-10,000-fold more frequent than the risk of viral infection. Rates of mislabelled samples and WBIT can be tracked as key indicators of performance of an important step in the clinical transfusion process. WBIT episodes represent important 'near-miss' errors. By providing baseline performance data for the collection of patient blood samples, this study may be useful in formulating future national standards of performance for sample collection from patients.
从正确的患者身上采集血样是安全输血流程的第一步。这项国际合作研究的目的是评估用于血型鉴定的样本标记错误和采集错误的发生率。
10个国家的医院提供了至少3个月期间（包括2001年最后一个季度）的样本错误率数据。标记错误的样本定义为不符合实验室当地验收标准的样本。采集错误的样本[管内血型错误（WBIT）]定义为血型检测结果与先前检测记录结果不同的样本。针对重复样本的比例以及因偶然从具有相同ABO血型的错误患者采集血液而导致的无法检测到的错误，对WBIT率进行了校正。参与者还完成了一份关于当前样本采集政策的问卷。
共有71家医院完成了关于样本采集相关政策的调查。62家医院提供了关于标记错误和采集错误样本发生率的可用数据。标记错误和采集错误的样本很常见。基于超过690,000个样本的结果，医院的中位表现导致每165个样本中有1个标记错误（每1000个中有6.1个；四分位间距为每1000个中有1.2 - 17个）。瑞典和芬兰存在国家患者识别系统，与之相关的采集错误样本发生率过低以至于无法估计。在这些国家之外，显示WBIT的采集错误样本的中位发生率为每1986个样本中有1个（每1000个中有0.5个；四分位间距为每1000个中<0.3 - 0.9个）。全球范围内报告的标记错误样本发生率差异很大，这可能是由于样本验收政策的差异所致。采集错误样本的发生率更为恒定。
标记错误样本和采集错误样本的发生率比病毒感染风险高1000 - 10000倍。标记错误样本率和WBIT率可作为临床输血流程中这一重要步骤表现的关键指标进行追踪。WBIT事件代表重要的“险些发生”的错误。通过提供患者血样采集的基线表现数据，本研究可能有助于制定未来国家患者样本采集表现标准。
