Technology-enhanced learning and proficiency based progression to investigate and mitigate ‘wrong blood in tube (WBIT)s’ in our hospitals; can we improve patient safety and reduce resource wastage?

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O'Herlihy, Nóirín
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University College Cork
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Background: Blood sampling errors are a frequent occurrence in healthcare. Wrong Blood in Tube (WBIT) errors are a serious blood sampling error that occur when the blood in the tube is not that of the person on the tube label. WBIT can lead to serious consequences including ABO incompatible blood transfusion with a risk of mortality, inappropriate diagnosis and inappropriate treatment of patients. Blood sampling errors are recognised globally. In Cork University Hospital (CUH), to maintain INAB accreditation at the laboratory, tracking and trending of blood sampling errors including WBIT is required. Since 2010, a steady incidence of WBIT errors was identified with a peak in incidence with the intake of new doctors to the hospital each July. Teaching by the medical school on phlebotomy, awareness campaigns and efforts by the haemovigilance team in the hospital failed to reduce the incidence of WBIT at CUH. Aim: The aim of this study is to develop a novel proficiency-based progression (PBP) training programme in phlebotomy, specific for CUH to reduce the incidence of blood sampling errors, especially WBIT. Objective: 1. Engage with stakeholders in the process of phlebotomy at CUH and with experts in the field of PBP to develop metrics to define the procedure of phlebotomy at CUH. 2. Develop a PBP training programme in phlebotomy, specifically for interns commencing work in the hospital consisting of 1) Online module 2) Face-to-face training on a simulated ward 3) Mentorship of the doctors performing phlebotomy on real patients according to the metric. 3. Perform a controlled clinical trial to determine if the introduction of the training programme resulted in a reduction in blood sampling errors including WBITs in comparison to blood sampling errors in a retrospective control group in 2016 before the study commenced. 4. An observational study took place on the wards to identify the barriers and facilitators to implementation of the instructions provided in the metric. Findings: A validated metric for performing phlebotomy at CUH was developed and used to develop a PBP training programme in phlebotomy. In the haematology laboratory, 43 interns in 2016 control group had an error rate of 2.4% compared to 44 interns in the 2017 pilot study, who had an error rate of 1.2% (OR=0.50, 95% CI 0.36-0.70 p-value<0.01). 46 interns in the 2018 follow-on group had an error rate 1.9% (OR=0.89, 95% CI 0.65-1.21 p-value=0.46). There were three WBITs in 2016 and 2017 and five WBITs in 2018. In the transfusion laboratory, there was a reduction in overall error rates with the introduction PBP training, but the reduction was not statistically significant. There was no blood transfusion WBIT in 2016, there was one blood transfusion WBIT in 2017, and no blood transfusion WBIT in 2018. During observations of interns performing phlebotomy on the wards, phlebotomy was found to take a median of 20 minutes (minimum 10 minutes, maximum 45 minutes). There were often poor practices promoted by difficulty locating patients, task disturbance, poor requesting practices acting as a barrier to positive patient identification, patients not wearing wristbands to identify them, and environmental factors such as stress and lack of safety culture. Conclusion: The effect of the PBP training programme in phlebotomy on the primary outcome WBIT was difficult to determine due to the rare occurrence of WBIT. There was not sufficient sample size to reach a statistically significant conclusion. Blood sampling errors appeared to be improving, but the effect size was smaller in the second year of the study possibly due to a reduction in the number of tutors available per group on the simulation ward and confounding. Observation of phlebotomy on the wards identified numerous barriers to key elements including positive patient identification, poor access to essential equipment and task prioritisation by busy doctors. Introducing bedside label printers and promoting a culture of safety are critical factors to improve the safety and reduce WBIT errors.
Wrong blood in tube , Blood sampling errors , Simulation training
O'Herlihy, N. A. 2020. Technology-enhanced learning and proficiency based progression to investigate and mitigate ‘wrong blood in tube (WBIT)s’ in our hospitals; can we improve patient safety and reduce resource wastage? MD Thesis, University College Cork.