The following list of resources is by no means fully inclusive. It is a collection of websites and tools that the ISBT TP subgroup would recommend to those investigating wrong blood in tube events.


International Society of Blood Transfusion (ISBT)

ISBT Transfusion Reaction Module

ISBT Haemovigilance

ISBT Posters -


SHOT and resources

Serious Hazards of Transfusion (SHOT)

file:///C:/Users/lbielby/Downloads/EN-2018-Why-2-Samples-SHOT.pdf  - Pre-transfusion sampling process



Ontario Regional Blood Coordinating Network (ORBCoN)

ORBCoN Transfusion Safety Officer Resource Manual


Blood Matters

Blood Matters program |

Blood Matters – ABCD of blood sampling poster – get it right first time, get it right every time

blood-matters-program-poster---doc.docx (

VMIA - Investigating the Human Factors behind ‘Wrong Blood in Tube’ (WBIT)

events in the Emergency Department



Patient ID poster – Do we Know wo you are? 2021-0259-pbm-patient-id-printable-patient-facing-a4-landscape.pdf (

Staff ID poster – Do you know who they are?

Taking a blood sample for pretransfusion compatibility testing poster-

Taking a blood sample for pretransfusion compatibility testing youtube -


Incident management guide

Australian Commission on Safety and Quality in Healthcare



Australian Red Cross Life Blood eLearning Adverse Events

SHOT Webinars

BloodSafe ELearning Australia -


Investigations – cause and effect, fishbone and why’s

Institute for Healthcare Improvement (USA)

Cause and Effect

Patient Safety Essentials toolkits – 5 Whys

Quality Improvement Essentials toolkits 

National Maternal & Child Health (USA),vid:wrVSpKt6veU

Harvard online - How to create cause-and-effect diagrams – YouTube

Uni Utah -

NSW-Australia-Clinical Excellence -



Mind tools -


Developing Recommendations

Safer Care Victoria - Developing recommendations.docx (


Improvement Science step by step guide

NSW Government – Clinical Excellence Commission Improvement Science - Step by Step Guide (May 2021) (



1. Br J Haematol. 2015 Jan;168(1):3-13. doi: 10.1111/bjh.13137. Epub 2014 Oct 4. Wrong blood in tube - potential for serious outcomes: can it be prevented? Paula H B Bolton-Maggs 1, Erica M Wood, Johanna C Wiersum-Osselton PMID: 25284036 DOI: 10.1111/bjh.13137

2. Transfusion. 2022 Jan;62(1):44-50. doi: 10.1111/trf.16716. Epub 2021 Nov 2. Factors associated with wrong blood in tube errors: An international case series - The BEST collaborative study Nancy M Dunbar 1, Richard M Kaufman 2; WBIT Study Investigators, The Biomedical Excellence for Safer Transfusion (BEST) Collaborative PMID: 34726274 DOI: 10.1111/trf.16716

3. Jt Comm J Qual Patient Saf. 2019 Mar;45(3):190-198. doi: 10.1016/j.jcjq.2018.08.010. Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Intraoperative Blood Component Administration. Nadia B Hensley, Colleen G Koch, Peter J Pronovost, et al. PMID: 30389466 DOI: 10.1016/j.jcjq.2018.08.010

4. Transfus Clin Biol. 2022 Aug;29(3):250-252. doi: 10.1016/j.tracli.2022.03.004. Epub 2022 Apr 27. The impact of a closed-loop electronic blood transfusion system on transfusion errors and staff time in a children's hospital. Yu Shi , Chengjie Ye , Hongsheng Wang, et al. PMID: 35489705 DOI: 10.1016/j.tracli.2022.03.004

5. Transfus Med. 2022 Aug;32(4):299-305. doi: 10.1111/tme.12863. Epub 2022 Apr 2. Sample collection for pre-transfusion crossmatching: Benefits of using an electronic identification system. Kyung-Hwa Shin , Hyun Ji Lee, Seung-Hwan Oh, et al. PMID: 35365920 DOI: 10.1111/tme.12863

6. Transfusion. 2010 Dec;50(12 Pt 2):2772-7. doi: 10.1111/j.1537-2995.2010.02943.x. Root cause analysis of transfusion error: identifying causes to implement changes. Priti Elhence , S Veena, Raj Kumar Sharma, R K Chaudhary. PMID: 21128948 DOI: 10.1111/j.1537-2995.2010.02943.x

7. Acta Med Iran. 2012;50(9):624-31. Root-cause analysis of a potentially sentinel transfusion event: lessons for improvement of patient safety. Hossein Adibi, Nader Khalesi, Hamid Ravaghi, Mahdi Jafari, Ali Reza Jeddian. PMID: 23165813


Root cause analysis articles

1. Hagley G, Mills PD, Watts BV, Wu AW. Review of alternatives to root cause analysis: developing a robust system for incident report analysisExternal link. BMJ Open Quality. 2019 Aug 1;8(3):e000646.

2. National Patient Safety Foundation. RCA2 - Improving Root Cause Analyses and Actions to Prevent HarmExternal link. Boston: NPSF, 2015.

3. Nicolini D, Waring J, Mengis J. The challenges of undertaking root cause analysis in health care: a qualitative studyExternal link. Journal of Health Services Research & Policy. 2011;16 Suppl 1:34-41.