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Ok, I'll start. The story of "Who turned off the Light". The year was 1999. Hospital "Notme Medical Center" supported an outpatient clinic for patients requiring transfusion, some due to sickle cell anemia. Often these were young adults that came into the clinic very early in the morning. After their blood was collected and they were waiting for the crossmatched packed red cell units to arrive, the patients preferred to sleep (pre i-phone years). Normally at least one light was left on, usually the bathroom light, while they were waiting. At 0530 the first of two tagged crossmatched compatible group O RH Positive red cell units was verbally crosschecked with the nurse Jane at the transfusion service door to be taken directly to patient Smith's room for transfusion. At 0625 the first of two tagged crossmatched compatible group B RH Positive red cell units was verbally crosschecked with nurse Kathy at the transfusion service door to be taken directly to patient Brown's room for transfusion. At 0633 nurse Kathy called the transfusion service to see if she could return the blood for patient Brown since someone had already started the first one. What! Said the BB technologist, the one I just checked out with you was the first unit for patient Brown. Follow-up: Nurse Jane had crossed checked the tagged red cell unit for patient Smith with another nurse at the nurses station and it was for a sickle cell patient in room 123 bed A. She went to the room she normally has gone to in the past, and when she looked into the room, although the lighting was low it was enough to see it was a young adult black patient in the room in bed A. Although a little groggy, the patient confirmed she was expecting the transfusion. After starting the unit, the patient appeared to tolerate the transfusion well and the nurse left the room. After speaking with the BB tech about returning the unit for patient Brown nurse Kathy went back to the room and discovered patient Brown was in bed A and had a red cell unit almost completely transfused but was unit was tagged for patient Smith. Patient Smith was in bed B. Both patients were young black adults but had switched beds because patient Smith did not want to be in the bed close to the door. Luckily the group O unit was compatible with patient Brown and was tolerated well by the patient. Needless to say, we required Nursing Education Services to review policies regarding the importance of patient identification and cross checking the tagged unit with another nurse at the bedside NOT at the nurses station. A poor practice that seemed to pop up once in awhile.

I had always found it difficult to convince nurses that we were working with a person/patient and not a room/bed! This became even more difficult after all the privacy rules and regulations came about. It was almost as if they were terrified to say a patient's name aloud!