Transfusion Errors

[mrmic 55]

Would there be any interest having a topic area to share transfusion error stories?   I thought it might be useful for Supervisors, QA and other transfusion services staff to hear accounts of problems that have occurred in other hospitals.  It could help with training laboratory, nursing and medical staff.  It could be lab error, patient ID error, transfusion error, donor center error, etc...  No specific person, hospital, blood center identification, state or country ID.

Or is there some taboo about putting this info out there?  If there is, we could say it is research for a new TV series.......

If there is no interest that's fine too, no worries.

[John C. Staley 1,180]

I especially like the way you phrased it as "transfusion error stories" and not transfusion horror stories.  Looking back I sometimes think I could write a book on the subject.  Well, maybe not a book but at least a novella!  Some of the stories would be comical and others terrifying.  Luckily, in over 35 years in the business none of my stories are fatal but a few had the potential.

 

[Malcolm Needs ★ 4,910]

In the UK, we have the SHOT Report (Serious Hazards of Transfusion) that reports every year, and has done so since 1996.  Their reports, which anonymise the reporter, are always both interesting and informative.

[mrmic 55]

SHOT report sounds a little "official".    Although I'm not suggesting that serious hazards of transfusions not be reported as required, there are some events that sometimes remain "in-house".  Having been in BB 40 years and worked for various transfusion services and few Immunohematology Reference labs for other hospitals there are some interesting stories to tell.  Some may be helpful to facilities with newer TS or QA management.  Some may be a little comical, some scary and some shedding some positive light on the lab saving the day.  Just thought it would be an interesting topic to read through and I'm sure everyone could share something.

Except for CSI, most series are nurses or doctors saving the day or coming to the lab and doing the testing (haha).

[Malcolm Needs ★ 4,910]

Oh, don't get me wrong.  I think it is a splendid idea because, as you so correctly say, people can learn from these things (even people with huge experience), but, believe me, SHOT is far from "official" in terms of people not reporting to it.  Actually, just the opposite has happened, and more and more people are, if you like, "owning up", because there is an absolute trust that there is a "no name, no blame" culture, as far as SHOT is concerned (the actual reporting laboratories may have a "proportional blame" culture if, for example, an SOP is ignored, but SHOT is totally "no name, no blame" as far as the individual is concerned).

[mrmic 55]

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.

 

 

 

[John C. Staley 1,180]

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!

[MAGNUM 100]

On 2/21/2021 at 9:56 AM, John C. Staley said:

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!

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.

 

[David Saikin 1,432]

We all have these transfusion event stories.  Rec'd a phone call in the middle of the night years ago.  3 out of 4 units were transfused to the incorrect patient.  Fortunately both pts were O Pos.  We used Typenex numbers.  BB tech switched the 2 patients; could only be resolved at the bedside. 2u transfused in dialysis.  When asked about the "red" numbers I was told that they no longer checked them as they always matched.  I informed them that they gave 2u the day before to the incorrect patient.

[slsmith 64]

My scary story is the time a nurse who transfused the wrong patient because she not only didn't compare the unit to the arm band but did not read the the unit off with another nurse. It was caught because the nurse of the patient that unit was meant for called the BB asking where her blood was. The transfusion was stopped before the whole   red cell could be given.  Fortunately for the patient the unit was O pos (his type) and antibody screen was negative.  Unfortunately for the  nurse she no longer has a job.

[BankerGirl 214]

That is a similar scenario to my most recent nightmare.  The nurse had given the patient multiple units of blood over two days so she "knew" he wouldn't have a reaction.  Then checked nothing and bypassed the computer transfusion program.  An aid came in the room when she was getting ready to transfuse unit #2 and noticed the blood type wasn't the same as the one she was discarding.  Fortunately the patient suffered no harm. 

[Malcolm Needs ★ 4,910]

1 hour ago, BankerGirl said:

That is a similar scenario to my most recent nightmare.  The nurse had given the patient multiple units of blood over two days so she "knew" he wouldn't have a reaction.  Then checked nothing and bypassed the computer transfusion program.  An aid came in the room when she was getting ready to transfuse unit #2 and noticed the blood type wasn't the same as the one she was discarding.  Fortunately the patient suffered no harm. 

WOW!!!!!!!!!!!!!!!!  THAT really is so scary!

[mrmic 55]

I had a BB technologist hand me the phone with a surgeon in the OR requesting two units of blood be brought to surgery, refusing to do any paperwork or provide a blood sample and a verbal order was all he would provide.  According to the physician, as the physician in charge in the OR that was all the justification needed we must do as requested.  That was the according to state law.  We did not have a BB certified pathologist at the time, the general pathologist indicated to comply with the physician's request, and had a Resident physician in the lab come get the units (O RH Negative) to take to the OR.  We had similar "to comply" situations with this "pathologist group" hired by the hospital corporate office.  The rumor was, if the "group" received poor ratings or complaints from the hospital physicians their contract would not be renewed.   When I began my laboratory career the pathologists were actually hospital employees and could tell physicians what they needed to do, the right thing to do,  without fear of a contract renewal.  The newer "corporate" model of hospital administration is scary to me.

[David Saikin 1,432]

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

[DPruden 129]

Decades ago, one of the night shift techs thought that doing a type confirmation on autologous units was stupid, so she would routinely "sink test" the ABO confirmations on autologous units.  this was during a time when many people were donating autologous units and having them frozen (early 1990s).  There were 2 auto units being deglyced at the same time at the blood center, and through an honest mistake by the donor center staff, the units were switched during labeling, one was OPOS and one was BPOS.  To further complicate the error, the patient didn't really need to be transfused, 30-something healthy guy in for jaw surgery, very minimal blood loss during surgery, but the unit was on the shelf and it was autologous, so they decided to transfuse it!  So, he got an entire BPOS unit and he was OPOS.  The patient spent about a week in ICU and his kidneys shut down for a while, but he survived with no long term consequences.   I will never forget that one!

[Ensis01 124]

Several years ago we had a call from the OR asking if there was any history on a patient X to determine if one collection or two separate collections were required. The BB tech who answered the call did a history search and said we have no BB history on patient X. Ten minutes later two samples for a patient Y arrived. The same BB tech called the OR to clarify why samples on patient Y were delivered when we were expecting patient X. The OR said patient X samples had been delivered. Not said the BB tech; and demanded two recollections by different people.

What had happened was patient X was moved to a different OR and whoever collected the samples used the labels in the new OR, patient Y (the labels for patient X  were in the old OR).  As whoever drew the samples recorded them as different collections; they were written up with two Wrong Blood in Tube events, which resulted in their termination.  

We typed the incorrect samples from curiosity and an O+ patient would have received A+ blood!!!!!!

[John C. Staley 1,180]

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!

 

[exlimey 383]

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

[Marilyn Plett 43]

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.

 

[yan xia 196]

It was decade ago, a nurse kindly gave the blood  crossmatched for A to B  after A passed away without having it . Because she thought  they were both type O pos. Luckly, B had no transfusion reaction.

[mrmic 55]

Definitely enough story lines for a mini-series!

These are all possible stories that could happen to any of us. 

Being in direct contact with physicians (who know everything) and nurses (who believe policy is not practice) and providing products that could be life saving or harmful to patients and parts of the process is out of BBs control can be very stressful for technologists.  And sometimes is hard to get new technologists to work in our field.

With providing administration with some of these "real" scenarios and the possible medical-legal-pr implications I was able to acquire an additional salary % for techs working full time in the transfusion service.  When other department techs thought it was unfair, I asked them to apply for a BB position (no takers).  Might be worth a try if you need techs.

Thanks to all who are sharing your experiences. 

[Sandi 13]

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!!! 

[jojo808 51]

I think we need to add an OMG emoji to our selections!