North Kansas City Hospital North Kansas City, Missouri, United States
Background/Case Studies: Transfusion is a complex, multidisciplinary process that begins with pre-transfusion specimen collection and processing. According to the College of American Pathologists (CAP), each mislabeling error can cost approximately $208 due to the need for specimen recollection. This cost includes repeat testing, additional supplies, and staff time.
Despite multiple interventions—such as staff education, training, competency assessments, and standardized guidelines, the specimen labeling error rate has remained unchanged. Errors are distributed across all staff involved in pre-transfusion specimen collection hospital wide. This retrospective study investigates the underlying causes of mislabeling to guide process improvements.
Study
Design/Methods: Causes of mislabeled specimens were examined over a two-year period through retrospective analysis of incident reports, specimen rejection logs, and root cause investigations. This comprehensive review aimed to identify common patterns, contributing factors, and system-level gaps in the pre-transfusion specimen collection process. Insights gained from this analysis informed targeted updates to the blood bank collection workflow, with the goal of reducing labeling errors and enhancing overall patient safety.
Results/Findings: Figure 1 below shows the reasons for mislabeled samples in 2023-2024. Common error themes in 2023-2024 include missing collection information/ electronic scanning overrides or failures, Blood Bank ID bands missing/ not used, unlabeled tubes, the Type & screen sample and the ABORh confirmation cannot be collected by the same individual. Data review revealed that in FY2023 there were 355 mislabeling errors costing $73,840 and in FY 2024 there were 401 mislabeling errors for a cost of $83,408.
Conclusions: Following a comprehensive review of root cause investigations and a two-year trend analysis, a proposal was introduced to discontinue the use of Blood Bank Identification Bands. The Blood Bank ID bands were implemented in 2004 to provide an additional patient identifier. There has been a consistent increase in specimen labeling errors linked to these bands each year. The use of Blood Bank ID bands is not mandated by regulatory agencies and were found to contribute to “cognitive overload.” Notably, they were linked to 27% of specimen rejections due to mislabeling—amounting to 100 documented errors—and their removal is projected to save approximately $29,200.
The decision supports streamlining the specimen collection and transfusion workflow without compromising essential patient identification safeguards. Key safety measures remain in place, including ABO confirmation by a second individual, the use of bedside barcoding, and expanded access to bedside printers, either as newly implemented or ongoing practices.
