(P-TS-64) Implementation and Quality Monitoring of Pre-Transfusion Sample Processes to Prevent Patient Misidentification and Incompatible Transfusion in a Pediatric Institution

Background/Case Studies: Accurate patient identification for pre-transfusion testing is critical in pediatric care with unique pediatric risks such as low blood volumes and complex naming. Clerical mislabeling and errors such as wrong blood in tube (WBIT), where specimens are incorrectly labeled with another patient's details, can cause transfusion-related adverse events with significant morbidity and mortality. To address this critical issue, we implemented a structured quality improvement initiative targeted at enhancing specimen labeling accuracy and reducing transfusion risks in our pediatric tertiary care facility.

Study

Design/Methods: We introduced a comprehensive, multi-component pediatric-focused protocol featuring dual-verification of bedside labeling by two independent personnel requiring two signatures, followed by verification by the blood bank, ensuring multiple accuracy checks. Additionally, we mandated a separate, second blood sample collection drawn at a distinct time from the initial specimen for ABO/Rh confirmation for all pediatric first-time transfusion recipients. Continuous performance monitoring involved regular analysis of specimen rejection rates, reported safety events (RISE), and potential WBIT indicators. Data collected from 2021 to 2024 were retrospectively analyzed to compare outcomes to internal pediatric goals and examine possible correlations.

Results/Findings: Over the study period, 34,977 pediatric type and screen specimens were analyzed. Annual rejections due to patient identification errors ranged from 96 to 119 and possible WBIT cases ranged from 7 to 13. RISE events increased progressively from 38 in 2021 to 61 in 2024. A statistically significant positive correlation was identified between total labeling-related rejections and occurrences of possible WBITs (Figure A). Internal goals for labeling error rejections (< 1.12% annually) were not met. However, there were no incidents of pediatric patient misidentification detected by second sample ABO/Rh confirmations, and no pediatric mis-transfusions during the review period.

Conclusions: Our pediatric-focused dual-verification labeling protocol, coupled with mandatory second sample collection and continuous performance monitoring, successfully prevented mis-transfusions in pediatric patients. Persistent pediatric labeling challenges indicate the need for sustained education and process vigilance. Future research should explore prospective studies, educational interventions, and technological enhancements to further mitigate labeling errors and improve pediatric transfusion safety. The demonstrated effectiveness of these layered pediatric risk mitigation strategies highlights their critical role in pediatric transfusion safety protocols.