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Back in the 80's, had a cardiac patient undergoing CABG and received 8 units B NEG RBC during surgery. Three days later, a new specimen was received that typed mixed field AB POS with a reverse type group A. Supervisor retrieved the chemistry specimen from 3 days prior and it typed as A POS. Turns out the phlebotomist drew the patient in the other bed and this was long before second sample requirements .... Patient was a little "oozy" post-operatively but survived the experience. Same hospital, elderly female patient typed as O NEG. Blood was crossmatched and issued during the weekly computer downtime. As I went through the stack of units that had been issued updating the computer records, got a major flag as at computer issue - the unit was A NEG and that was just the first of 2 units that had been issued during this 2 hour downtime. Investigation revealed that 2 A NEG RBC were placed in the O NEG inventory, were crossmatched using immediate-spin and were compatible, and out the door they went. The patient was fine.

I just had to share this story...When I worked in a large teaching hospital we had a team of Transfusion Nurses who were responsible for drawing most samples and administering the transfusions. Occasionally, however, physicians (or interns/residents) would draw the samples. One afternoon we received an unlabeled sample drawn by a physician via courier. We contacted the physician and informed him a new sample would have to be drawn. He said he would come to the transfusion service and label it right away. We told him that was unacceptable, however, he insisted. While he was on his way, we put together several samples without labels and placed them in a rack. When he arrived, we presented the rack to him and told him to select the sample to label. He actually tried to feel each tube to find the warmest one and said that was the sample he sent. Obviously we did not allow the sample to be labeled. The story has been told many times!!!

I have even gone so far as to tell the nurse taking care of the patient that when they learned the patient's name and not the room number to give me a call back and we will discuss the patient at that time.