Dismiss tech or keep with restrictions

[SantaFe Jane]

Should a tech be dismissed immediately for missing an anti-Kell on patient's record (titer is low and ab screen is negative, units not Kell typed and coombs crossmatches not performed. Both units were transfused. Tech works 3rd shift and director believes that should he go, scheduling becomes a nightmare)?

[Lcsmrz]

Scheduling should not be an issue when deciding corrective action, nor should whether the units were actually Kell-negative. You could place yourself in jeopardy of a lawsuit for inconsistency or for placing your patients at risk for not dismissing a marginal employee.

But you need to review the system and contributing factors to see if the system contributed to the error, and your HR department may be able to help. Did your computer detect the omission and issue a warning that was ignored? Is the midnight shift short-staffed and under workload or TAT stress? Is the employee error-prone, or is this the first serious error that the tech made in 20 years of otherwise exemplary service? Did the worker just work 13 straight nights, so you don't have to come in to give him a day off? Does the director have it in for midnight shift workers? On and on ...

It's easy to say one big strike and you're out, but techs often struggle to make a bad system work, and an error of some magnitude is sometimes inevitable, given enough time. To me, ignoring a computer-generated warning would carry more weight, than missing a misfiled card in a manual system.

[John C. Staley]

Immediate dismissal without additional information would probably not be a good idea. I agree with most every thing stated by Lcsmrz. As long as humans are involved human error will occur. All we can hope for is to minimize it as much as possible and learn from it when it happens. Our current computer system generates so many warnings that many of the techs suffer from warning overload. (It actually warns us that A+ FFP is not the same type as an A= patient). They get meaningless warnings all the time and if they are expecting one and a different (important) one comes up they may not even read it. Is that acceptable, no, but it is human. I suggest that you weigh all the factors involved before making such a dramatic decision.

[Art]

Root cause analysis of the error should occur before any decision is made.

Procedures, training, quality control, communications, human engineering and management of those systems should be addressed prior to assigning fault.

If the tech is dismissed, are you setting up the next one for failure? Why aren't the rest of the techs making this error?

After the Root cause has been addressed, corrective action and an effectiveness check(of the corrective action) should follow.

The system is only as good as the weakest link in the chain--unfortunately, the tech is the most visible when errors occur. If the tech is at fault, disciplinary action should occur according your written policies in the department or with HR involvement(keep the lawyers out of it!).

[Myella]

How did the repeat Kell antigen typed come out? It might have been negative (80% are usually Kell neg) and the repeat crossmatches compatible. A written lettergram about the mistake might be sufficient at this time.

Maybe putting some work restriction and monitor for 1-3 months, if more error occurs.

According to studies, it's been shown that 80% of errors are management controllable and 20% of errors are human controllable. People don't want to make mistakes. It is different if it is due to gross negligence or intentional. Is your system error-proof? It might have been an accident waiting to happen. Take a good look at your system before jumping into conclusion.

[conwaysbb]

Just out of curiosity, does your blood bank have a comoputer system or are records only manual. As stated above, you should always consult your HR department and review disciplinary procedures. As this needs to be captured by your internal event reporting system, whatever that is, you could show what steps you took to investigate the event and document follow-up, for what ever you do.

I would further say that if you are indeed on a manual system, this event could be the focus point on why you need to get a computerized system into your blood bank. All the major blood bank computer systems have checks and balances to prevent a patient with a history of kell from receiving a unit that is not at least kell typed and a AHG x-match required. It is a gold standard in the blood banking community to have a computerized system and those facilities that do not have one are at some risk for legal liabilities if sonmething happened to the patient.

[luhubert]

We had a similar problem with a tech who worked infrequently in BB. We certainly didn't dismiss her. We did a root cause analysis, found some procedural changes to make. Made the Blood Bank techs different levels of competency and certain levels can only perform certain things. We put all our highest levels (3 of them) on a rotating call schedule to help techs that are on lower levels. I don't think dismissing is the answer unless the errors are done willfully or repeatedly without improvement.

[Pailloz]

I would have to evaluate the prior performance issues of that employee and evaluate your patient history check procedure. I agree this decision is VERY dependant on the computer system versus a manual system. If you had a computer system AND the tech blew pass repeated flags for "antigen not tested" & f"ull crossmatch not completed" AND there was documented evidence of prior poor technique by this tech then I may side with the manager. The tech is dangerous.

IF, on the other hand, (as I beilieve) you have a manual CARD system & the tech just didn't find or SEE the Kell AND he was following routine procedure otherwise, I would do the root cause analysis with the tech as part of an educational development project. I may go so far as a documented verbal warning if that is HR's first step of deicipinary action. Sometimes those techs that make the mistakes can be the front line for turning around a weak system and developing a better one.....ie COMPUTER!!

[Cliff]

Nancy,

Looks like you got lot's of terrific suggestions, now you'll need to work this out with your director. I was involved once in a situation where a 12+ year phlebotomist collected a sample from the wrong patient. The patient was transfused with 12 A units and they were actually an O. The patient did well, settled for an undisclosed amount. The directors were all in favor of letting this person go. I adamantly voted against, and fortunately policies were changed that included disciplinary action, not immediate dismissal.

You might also want to remember that these forums are public, and this 3rd shift employee might hear about their imminent demise from here.

Should a tech be dismissed immediately for missing an anti-Kell on patient's record (titer is low and ab screen is negative, units not Kell typed and coombs crossmatches not performed. Both units were transfused. Tech works 3rd shift and director believes that should he go, scheduling becomes a nightmare)?