The United Christian Hospital mishap on October 14 in which staff mislabelled two patients' blood specimens involved human and system factors, an investigation panel has found.

The incident, resulting in an unnecessary blood transfusion for a man while causing a delay in a woman's transfusion was noticed on October 15 when exams and blood tests were being conducted for the two patients.

The panel has made nine recommendations for improvement. They are:

* providing refresher training for hospital staff;

* conducting audits to ensure compliance of standard operation procedures;

* using pre-printed labels with the patient's name and identity card number as two unique patient identifiers for specimen labelling, instead of using the number tag of the request form as a label;

* reiterating to laboratory staff they should handle one specimen at a time;

* implementing auto-numbering to minimise manual handling when the computer system is in use;

* enforcing "one request form and its related specimen(s), one bag" policy in transportation;

* improving manpower deployment to handle manual registration when the computer system is down;

* reviewing standard operation procedures to reduce system errors; and,

* considering a back-up system during computer downtime.

The hospital has accepted the recommendations and will implement the improvements. Monitoring of operational procedures and staff awareness has been enhanced. A verbal warning has also been issued to staff.