Programs to monitor the risk of misidentifying pretransfusion blood samples

A colleague in Virginia comments that the College of American Pathologists (CAP) newest Transfusion Medicine Checklist (implemented in December 2004) has a new Phase 2 item "TRM.30550" which reads, "Does the facility have a documented program to ensure that the risk of pretransfusion sample misidentification is monitored and subjected to continual process improvement?" Associated with this new Checklist item is the following comment: "Approximately 1 in 1,000 specimens for pretransfusion testing are mislabeled.

Multiple methods exist to reduce the incidence of mislabeling, including: (1) documenting the ABO group of the intended recipient on a second sample collected at a separate phlebotomy; (2) identification of the intended recipient by a mechanical barrier or electronic identification verification system that ensures that the patient from whom the pretransfusion specimen was collected is the same patient as the intended recipient; (3) issuing only Group O units for transfusion; or 4) documentation in laboratory records of a previous determination of the recipient's ABO group from a correctly labeled specimen."

She wonders how others intend to comply?

Editor's note: Colleagues may find the links to previous e-Network Forum discussions that address some of the methods mentioned in the commentary of new CAP checklist item TRM.30550 to be germane answering the question raised by the Virginia blood banker:

Submit comments to the e-Network Forum at enetworkforum@cbbsweb.org

Ira A. Shulman, MD
CBBS e-Network Forum Senior Editor & Moderator

W. Tait Stevens, MD
CBBS e-Network Forum Editor & Moderator

Elizabeth M. St. Lezin, MD
CBBS e-Network Forum Associate Editor & Moderator

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