Mislabeled Patient - not specimen

[tricore]

Scenario

A patient is admitted to a hospital with a medical record number (MRN) belonging to someone else. Admitting selected the wrong patient in the hospital information system.

The information system used by the blood banks is different from the information system used by the hospitals.  Multiple hospital systems, all of the blood banks use the same blood bank information system.

Patient has a type and screen and four RBCs transfused.

Now the hospital has figured out that the patient's data is on the wrong MRN.

They admit the patient with his own MRN, reband the patient, and move all of his information from the incorrect MRN to the correct MRN by moving the episode in the hospital information system. 

There is no question that the blood products were transfused to the patient they have now relabeled. All information matched at the time of the transfusion.

How do you correct the records in the blood bank system? The system has the capability to tranfer the episode from the incorrect MRN to the correct MRN.

[L106]

I think I must be missing something, because this sounds too easy.

 

If your last sentence is true, then simply transfer the episode from the incorrect MRN to the correct MRN. 

 

 

Donna

[Liz0316]

Can you remove the status of the units and return them to inventory, then re-issue to the correct patient?

Liz

[Dr. Pepper]

I agree, both of the above fixes should work. If you're still worried about documentation you can always tack a comment onto the units explaining what happened.

Edited April 24, 2015 by Dr. Pepper

[tricore]

Yes, the easiest, neatest, and most logical method is to move the episode. Meeting some resistance there even thouigh the the hospital has already moved the episode in the hospital system. As for releasing and setting up the products on the new MRN: we do electronic xm. That will be in the hospital system. We cannot do an electronic xm unless we have a current type and screen.

One school of thought is to put "disregard results" in the incorrect record and nothing in the correct record. We could put notes in all of the unit records stating that the units really went to MRN number one. Then we wouild have to put notes on MRN number two stating what units were received for look back purposes in case the patient was found to have a transmissible disease. Of course, then there would be no record of the crossmatch performed. This can get really messy if the patient received many products.

Another consideration is all of the down stream systems to which we send information.