Volume 8 | Issue 5 | September 16, 2014

Preventing WBIT

New Initiative Targets Blood

Bank Mislabeling Errors
By Tyler Smith

Four letters WBIT spell a big danger to patient safety that

University of Colorado Hospital aims to address with a new
initiative.
The letters stand for wrong blood in tube. Its a medical error that
could lead to death or serious injury for a patient who receives a
transfusion of the wrong blood type. Even if providers catch a WBIT
error before a procedure, the mistake means that a patients blood
must be redrawn, delaying care and wasting resources.

All the errors could have led to hemolytic reaction and death,
West said. Were also postponing patient care.
Read the label. The hospital also identified a total of 342
instances of Blood Bank sample mislabeling in fiscal 14. The great
majority (89 percent) of those resulted from smudging of the initials
of the person drawing the blood or from a missing second set of
provider initials, which has been required since 2010. All of those
errors required blood redraws to ensure patients blood samples
matched the identifying tube labels and prevent harm.
An effort launched in late August is designed to raise awareness of
the dangers of WBIT and other mislabeling errors and reinforce the
protocol for drawing and administering blood products. It follows
a QSA-initiated drive in June to reduce the number of mislabeled
blood specimens sent to the Clinical Laboratory.
The new Blood Bank campaign includes requiring providers to
complete two ULearn modules, sending out an email blast and
flyer summarizing the importance of properly labeling samples, and
delivering ongoing education by QSAs on each unit, said Cardiothoracic
ICU nurse Melanie Bornemann-Shepherd, RN, who co-chairs the
QSA Committee with West.

In fiscal year 2014 (July 1, 2013 to June 30, 2014), the Blood Bank
at UCH documented 14 WBIT errors, up from four the year before.
All were caught before they reached the patient, so none caused
death or injury, but that doesnt diminish the seriousness of the
miscues, said Courtney West, RN, a clinical nurse in the Medical
Intensive Care Unit who co-chairs the hospitals Quality and Safety
Advocates (QSA) Committee.

The approach also emphasizes auditing samples for compliance

with the protocol. Under a progressive accountability process,
providers who mislabel a sample will have to repeat the ULearn
modules. A second occurrence will require a record of conversation
with the unit manager; a third will mean a written warning in the
providers permanent record.
Increased accountability. Janna Petrie, RN, CCRN, critical care
quality specialist with Clinical Excellence and Patient Safety (CEPS)
Continued

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Volume 8 | Issue 5 | September 16, 2014 | Page 2

and mentor for the QSAs, emphasized that punishing employees

is not the objective of the initiative. We are a just culture, but we
are professionals and we have to protect our patients, she said.
West said the QSAs also want to elevate the importance of
following the proper protocol for drawing blood for transfusion
each and every time. The process requires the provider drawing the
blood to positively identify the patient at the bedside and ensure
that the zebra label for the blood sample tube matches the name
on the patients identification wristband. After drawing the blood,
the provider must initial the label at the bedside, then have a
second person verify and read back the identifying information and
add his or her initials to the label. The label must clearly show both
sets of initials and be free of smudges.

The hospital implemented the double-initial requirement in 2010

after mislabeled blood samples led to two WBIT sentinel events.
The number of mislabeling errors decreased sharply during the next
three years, Petrie said, before rebounding in 2014.
Staff turnover, heavy patient volume, and growing workload pressures all could have contributed to the increase, campaign leaders
said. But none of these can be an excuse for rushing through steps
designed to protect patient safety, said Sandra Godcharles, RN,
quality care improvement specialist with CEPS.
There has to be accountability, Godcharles said. Its important for
providers to understand, she added, that even if a patient escapes
harm, redrawing blood wastes manpower hours.
Early indications are that the efforts to reduce labeling errors on
samples sent to the Clinical Lab have been effective, Petrie said.

Were looking to see if those gains hold, she said. The QSAs will
keep a similarly close eye on the Blood Bank project.
Well re-evaluate for improvement, Bornemann-Shepherd said. In
the meantime, she added, its important that staff feel comfortable
reporting errors via Safety Intelligence, the hospitals online system
for tracking occurrences that caused or could have caused patient
harm. Such reporting helps the hospital implement changes in the
system that improve patient safety.
We want to be transparent and create a learning environment for
staff, Bornemann-Shepherd said.