A mislabeled tube can cause problems:
(1) in the blood bank, with transfusion of ABO-incompatible blood
(2) in misleading laboratory results
Risk factors for WBIT:
(1) container not labeled immediately at the bedside
(2) failure to verify the patient's identity at the time of collection
(3) two patients with the same or similar name
(4) clinician overconfidence
(5) failure to adhere to specimen labeling policy
(6) label mix-up (label out of sequence, etc)
(7) emergency care, especially associated with a disaster
(8) lack of training related to specimen identification
(9) error at registration
Failure to verify identity may occur if:
(1) the patient is unconscious or intoxicated
(2) the patient does not speak the same language
(3) the armband has been removed
(4) the patient has no identification (John or Jane Doe)
(5) the collector does not adequately check
Some phlebotomists write the name of the patient on a tube at the time of collection and the label is affixed later. When troubleshooting a WBIT it can be helpful to see if there is a patient identifier under the label.
