Transfusion Errors

[David Saikin]

1 hour ago, applejw said:

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.

Just curious - doesn't your staff have to look at the product they are releasing for transfusion?  Did that patient get both of those units or was the 2nd one also given to a O Neg?

[David Saikin]

On 4/2/2021 at 10:56 AM, Sandi said:

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've had scenario a few times in the past.  Someone will always come and label an unlabeled tube.  I tell them it broke in the centrifute.

[Mabel Adams]

Years ago in a hospital far away we had a blood refrigerator in the OR central core.  I received a stat T&X specimen from OR and proceded to complete the work.  I got a blood product request from from OR before the workup was complete so I phoned to notify them that I would not send the blood until the crossmatch was done (of course they could have requested uncrossmatched which they didn't).  Not much later I got a call from the nurse anesthetist and her voice had terror in it.  She said that she had spiked a unit that was in the fridge to hang on the patient (O pos) I was still testing and then she checked ID against the unit and discovered it was for a different patient (A pos). then she called me fully aware of how close she had come to hanging A blood on an O patient.  The OR had a bad habit of not returning units to the blood bank from surgeries at the end of the day and the A pos unit was for a patient who had surgery the prior day.  They were the only units in the fridge so she assumed htey were for her patient.  The OR desk must not have relayed the message about the delay. There are ways and processes for making remote fridges safer (although TJC recommends against them) but that hospital promptly removed the fridge from OR and we started issuing blood in coolers with the patient ID on them that could be taken to each room.  They were much better about returning unused blood and we were aware if a cooler had not been returned so could call for its retrieval.

[Mabel Adams]

On 3/10/2021 at 4:46 AM, David Saikin said:

fortunately/unfortunately this scenariooccurred where I was working.  Patient w acute gi bleed at a hospital not close to us.  Transfused 20 group B plasmas and 16 group B rbcs.  Patient under control and transferred to our hospital.  On day 2 we  gave him 2 B plasmas.  On day 4 we had a request for 2 rbcs.  Patient still typed as B+ with a lot of unagglutinated cells in the front type.  Those cells typed as O=.  The patient's bili went from 2 to 31 in the next 16 hrs and they expired.  Turns out the patient was a known O=.  ER doc drew bloods and put in pocket; labelled later (obviously mislabelled).  BB tech fired as patient was in their file (sent to us because we would not know.   We turned the other hospital in to the FDA for the transfusion associated death (as we had not transfused any rbcs).

this is a scary story

Was this the case that was written up once in the CAP survey educational information 15-20 years ago?  I've always remembered that it was a B pos patient.  Although I think in that story the receiving hospital typed him as B (didn't notice the mixed field or assumed it was O given to a B patient) and kept giving B blood until he expired.

[David Saikin]

On 6/25/2021 at 3:30 PM, Mabel Adams said:

Was this the case that was written up once in the CAP survey educational information 15-20 years ago?  I've always remembered that it was a B pos patient.  Although I think in that story the receiving hospital typed him as B (didn't notice the mixed field or assumed it was O given to a B patient) and kept giving B blood until he expired.

No, we did type him as a B and gave him a few B plasmas.  However, they wanted blood on the 4th day after admission and that is when we found the unagglutinated cells (which were O Neg).