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This is the best thread, EVER !!!! Keep it rolling, please.

Back in the 70's, two patients with identical names and identical hospital ID numbers except for one number were in rooms across the hall from each other. The O patient received the red cells intended for the B patient. I discovered the error when I accidentally entered the wrong room to collect a transfusion reaction specimen and did my due diligence on patient identification. Subsequent new admission rules forbade having two patients on the same wing with the same name.

I've been searching for the powerpoint I made of the occurrence I wanted to share but I must have stored it on an external hard drive that crashed and was unrecoverable. (That's my excuse anyway.) Consequently it was long ago and my memory is fuzzy on the details but in this case the details is not the point I'm attempting to convey. Bottom line was that 2 units of blood were sent via pneumatic tube to ICU for 2 different patients. No, the units were not in the same tube, they were sent 10-15 minutes apart. The units went to the wrong patients and the proper patient identification protocol was not followed. Both units were transfused and the paper work was sent back to the transfusion service. I do remember a very white faced staff member coming to my door to tell me what they had discovered. Luckily both patients were type O+ with no problems and recrossmatching showed that each was compatible with the unit they had received. We had dodged a bullet! The ensuing investigation discovered that the patient identification protocol used by the ICU nursing staff had morphed into something I did not even recognize. A couple of years earlier the nursing department had taken over all training of new nurses as well as annual reviews for current staff. They basically told me my services were no longer needed in a training capacity. When the details of the occurrence came out the assistant CNO (chief nursing officer) who was filling in for the CNO on sick leave wanted to severely punish the two nurses involved and then sweep everything under the rug. Heaven forbid that word got out that a couple of HER nurses had made a mistake. Much to my surprise and delight I was able to convince the ICU nurse supervisor that the problem was much deeper than just human error and the protocols the nurses were following were deeply flawed. We did extensive retraining for the entire ICU staff. When the CNO returned to duty I had a long talk with her. I had always had a very good relationship with her and she trusted me. From that point on I was actively involved in the training a new nurses as well as the annual refresher courses for current staff. During those training sessions I was not surprised that other areas had "adjusted" the pretransfusion patient identification protocols to be easier and quicker for them. Using this occurrence as an example I was able to convince them of just how critical patient identification was. As a side note, I one time had a labor and delivery nurse tell me that it was impossible for her to transfuse the wrong blood to her patient and nothing I could say would convince her otherwise. Some times I wonder how I ever got out with my sanity intact! My wife (a nurse) reminds me that I didn't!

Hi Stephanie, I am not sure that you, as a collection facility, need to perform this test. I suspect most donor centers do not. We have a hospital based donor center and label our products in our component lab and then confirm their type in our transfusion service. I have no idea if donor centers we purchase blood from do a confirm type, regardless, we always confirm the type of a product in our transfusion service before we make it available. AABB 5.9.5 There shall be a method to confirm that the ABO/Rh label is correct. Confirmation shall be performed after the ABO and Rh label has been affixed to the units.