Varey A, Tinegate H, Robertson J, Watson D, Iqbal A
Transfusion Quality Co-ordinator, James Cook University Hospital , Middlesbrough, UK.
Transfus Med. 2013 Oct;23(5):321-5. doi: 10.1111/tme.12050. Epub 2013 Jun 29.
Wrong blood in tube (WBIT) describes a transfusion sample collected from one patient but labelled with the identification details of a different patient. These incidents have the potential to result in catastrophic harm to patients. In 2011, the Serious Hazards of Transfusion (SHOT) organisation received 469 reports of WBIT across the UK.
This was a prospective study of WBIT which collected information not only on the frequency of WBIT but also risk factors.
All hospitals in the North East region of England submitted details of known WBITs during a 12-month period starting from July 2011, including the time of day and location where samples were taken, the job title and competency of the sample taker, and how the WBIT was identified. Where possible, the sampler was interviewed to determine reasons for the WBIT.
There were 48 WBITs, giving a corrected incidence of 1 : 2717 repeat transfusion samples. Doctors were responsible for 24 of 45 WBITs where the identity of the sampler was known. The rate as a proportion of samples was highest in medicine and paediatric specialties. The commonest risk factor for WBIT was labelling away from the bedside (44%).
These findings support, and add to, the data collected by SHOT. If our figures are representative of the whole of the UK, then over 1160 WBITs will occur each year, justifying SHOT's concerns that WBITs are under reported. Interventions are needed to ensure labelling of transfusion samples is always carried out at the patient's side.
采血管内血液错误（WBIT）是指从一名患者采集的输血样本却贴上了另一名患者的识别信息。这些事件有可能给患者带来灾难性伤害。2011年，输血严重危害（SHOT）组织在英国收到了469例WBIT报告。
这是一项关于WBIT的前瞻性研究，不仅收集了WBIT的发生频率信息，还收集了风险因素信息。
英格兰东北部地区的所有医院提交了从2011年7月开始的12个月期间已知的WBIT详细信息，包括采血的时间和地点、采血者的职位和资质，以及WBIT是如何被识别的。在可能的情况下，对采血者进行了访谈以确定发生WBIT的原因。
共有48例WBIT，校正后的发生率为每2717例重复输血样本中有1例。在已知采血者身份的45例WBIT中，医生导致了24例。按样本比例计算，发生率在医学和儿科专科中最高。WBIT最常见的风险因素是不在床边贴标签（44%）。
这些发现支持了SHOT收集的数据，并对其进行了补充。如果我们的数据代表了整个英国，那么每年将发生超过1160例WBIT，这证明了SHOT对WBIT报告不足的担忧是合理的。需要采取干预措施以确保输血样本的贴标签工作始终在患者床边进行。
