{
  "id": "medical/transfusion-recipient-identification",
  "signature": "AI instructs to use a patient's room number or bed label for pre-transfusion blood sample labeling instead of wristband barcode, causing wrong blood in tube (WBIT) error",
  "signature_zh": "AI指示使用患者房间号或床位标签代替腕带条码标记输血前血样，导致试管内血液错误（WBIT）",
  "regex": "(?i)(room.number|bed.label|bedside.label).*(blood|type|crossmatch|sample|specimen)|wrong.blood.in.tube|WBIT",
  "domain": "medical",
  "category": "auth_error",
  "subcategory": null,
  "root_cause": "Using room number or bed label for sample identification bypasses the two-person verification and barcode scanning required by AABB standards, leading to mislabeled specimens that can cause ABO-incompatible transfusion and fatal hemolytic reactions.",
  "root_cause_type": "generic",
  "root_cause_zh": "使用房间号或床位标签进行样本标识绕过了AABB标准要求的双人核对和条码扫描，导致标本标签错误，可能引起ABO不相容输血和致命性溶血反应。",
  "versions": [
    {
      "version": "AABB Standards for Blood Banks and Transfusion Services 33rd Ed (2023)",
      "introduced": null,
      "deprecated": null,
      "removed": null,
      "behavior_change": null,
      "status": "active"
    },
    {
      "version": "FDA Guidance: Fatalities Reported to FDA Following Blood Collection and Transfusion 2022",
      "introduced": null,
      "deprecated": null,
      "removed": null,
      "behavior_change": null,
      "status": "active"
    },
    {
      "version": "Joint Commission National Patient Safety Goal 01.01.01 (2024)",
      "introduced": null,
      "deprecated": null,
      "removed": null,
      "behavior_change": null,
      "status": "active"
    }
  ],
  "os_specific": {},
  "dead_ends": [
    {
      "action": "",
      "why_fails": "Writing 'Room 302 Bed A' on the label because 'the nurse knows which patient it is' — does not meet AABB identification requirements; any misidentification leads to WBIT",
      "fail_rate": 0.85,
      "condition": "",
      "sources": []
    },
    {
      "action": "",
      "why_fails": "Using a pre-printed label from the chart without verifying against the wristband — labels can be misplaced or belong to the wrong patient",
      "fail_rate": 0.7,
      "condition": "",
      "sources": []
    },
    {
      "action": "",
      "why_fails": "Scanning the wristband but then hand-writing the label without barcode — hand-written labels are prone to transcription errors",
      "fail_rate": 0.6,
      "condition": "",
      "sources": []
    }
  ],
  "workarounds": [
    {
      "action": "Use barcode wristband scanning at the bedside: scan patient wristband -> scan label -> apply label to tube. Two identifiers required (name + DOB or MRN). Verify with: `python -c \"import hashlib; print('Scan patient wristband barcode, then scan blank label, then apply label at bedside. Confirm: name=' + input('Enter patient name: ') + ' DOB=' + input('Enter DOB: '))\"`",
      "success_rate": 0.98,
      "how": "Use barcode wristband scanning at the bedside: scan patient wristband -> scan label -> apply label to tube. Two identifiers required (name + DOB or MRN). Verify with: `python -c \"import hashlib; print('Scan patient wristband barcode, then scan blank label, then apply label at bedside. Confirm: name=' + input('Enter patient name: ') + ' DOB=' + input('Enter DOB: '))\"`",
      "condition": "",
      "sources": []
    },
    {
      "action": "Implement electronic positive patient identification (ePPID) system: use handheld device to scan wristband, print label at bedside, and apply immediately. Document: `Sample collected via ePPID at 14:30, wristband scanned, label printed and applied at bedside.`",
      "success_rate": 0.95,
      "how": "Implement electronic positive patient identification (ePPID) system: use handheld device to scan wristband, print label at bedside, and apply immediately. Document: `Sample collected via ePPID at 14:30, wristband scanned, label printed and applied at bedside.`",
      "condition": "",
      "sources": []
    }
  ],
  "workarounds_zh": [
    "Use barcode wristband scanning at the bedside: scan patient wristband -> scan label -> apply label to tube. Two identifiers required (name + DOB or MRN). Verify with: `python -c \"import hashlib; print('Scan patient wristband barcode, then scan blank label, then apply label at bedside. Confirm: name=' + input('Enter patient name: ') + ' DOB=' + input('Enter DOB: '))\"`",
    "Implement electronic positive patient identification (ePPID) system: use handheld device to scan wristband, print label at bedside, and apply immediately. Document: `Sample collected via ePPID at 14:30, wristband scanned, label printed and applied at bedside.`"
  ],
  "transition_graph": {
    "leads_to": [],
    "preceded_by": [],
    "frequently_confused_with": []
  },
  "official_doc_url": "https://www.aabb.org/standards-accreditation/standards/standards-for-blood-banks-and-transfusion-services",
  "official_doc_section": null,
  "error_code": "TRANSFUSION-ID-ERR-005",
  "verification_tier": "ai_generated",
  "confidence": 0.89,
  "fix_success_rate": 0.88,
  "resolvable": "true",
  "first_seen": "2024-04-05",
  "last_confirmed": "2024-06-01",
  "last_updated": "2024-06-01",
  "evidence_count": 1,
  "tags": [],
  "locale": "en",
  "aliases": []
}