Status:
Ready to upload
Record number:
1684
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Very rare
Time to detection:
Detected during testing prior to release of report.
Alerting signals, symptoms, evidence of occurrence:
Blood group result did not match previous results on the same patient.
Demonstration of imputability or root cause:
The electronic scan of the bar code read a different identification number to the eye-readable number printed on the label. The authors interpreted this as an error due to a printer resolution defect. However further analysis has shown the print quality to be good but the printed barcode to be for a different number to that shown in eye readable text. Root cause of this error has not been determined.
Groups audience:
Suggest new keywords:
barcode
automation
identification
Reference attachment:
Suggest references:
Barcode error leading to sample misidentification during blood grouping, Shamee Shastry, Sreedevi Sreelekshmi, Manish Raturi, and Poornima Baliga, TRANSFUSION 2016;00;00–00
Expert comments for publication:
The error described is very rare. Barcoding is widely used in pathology and reports of misreads are uncommon. The authors attribute the misread to poor printer resolution but examination of the barcode shown in the video clip shows it to be of acceptable quality. However the number encoded in the barcode is different to that printed on the label. This would appear to be a process or software error rather than a resolution error, and would not be impacted by the type of bar code used.