tech errors transfusion of incompatible blood

[redwiner]

A error was made in typing a patient (no bb computer system). First tech had done Type & Screen. Reactions of ABO were written down correctly, but interpretation was not (Patient was B neg, type interp. as A neg). Following tech repeated type when doing the IS xmatch. Type interp. erorr was repeated by 2nd tech (next line on log sheet). IS xmatch apparently was not done, or not interpreted correctly. Patient was transfused.

This was a small lab, tech was working alone (also w/o a phleb, because someone had called in sick). They have been working for over 20 years without significant errors. Would you fire them?

[bmarotto]

Normally, if both employees do not have a history of making significant errors, I would say no to firing but would give a warning and document that you have counseled them on the seriousness of this sort of error. What bothers me is the second tech. I can understand repeating the same ABO error since you are not computerized. Tech #2 writes down the same reactions and sees they are the same that tech #1 wrote on the previous line so it is easy to see how writing down the same interpretation followed. You may want to implement a procedure where repeat blood types are recorded on a separate worksheet then the intepretation is matched with the interpretation of the original type on the main log sheet.

Now, what about that IS xmatch? If the patient has a normal back type, you would expect a 3-4+ incompatible reaction. THAT is pretty hard to misinterpret. Is there any chance that tech #2 is cutting corners by not actually performing the IS xmatch? Or maybe tech #2 got distracted by another lab task and honestly thought he/she had performed the IS XM but forgot to write it down so went back and recorded a negative reaction. If your lab is that small, I would think your Xmatch volume is also small so maybe having techs save IS xmatch tubes until a supervisor reviews the daily work would prevent the temptation to skip the IS xmatch. Maybe you would pick up some cold reacting antibodies but you would at least know the IS Xmatch was done.

[John C. Staley]

Based on the info you provided, absolutely not. There has to be more to it. Other things going on, distractions not accounted for. How many other tests were running in the rest of the lab at the same time.

I agree with Bev that my biggest concern is with the second tech and the IS crossmatch. That is a little fishy but I would still want more info before making any radical moves.

You may have just been handed the best reason for either a computer system, automated pre-transfusion anaylzer or both.

:eyepoppin

[jhaig]

You say the patient was transfused. Did the patient survive? A patient fatality will definitely complicate things, not only in the lab, but hospital administration, media, etc. If there was a fatality, there will be a call for someone to lose their job somewhere.

I would launch a full investigation before firing anyone. I agree with the others that the IS crossmatch results are sketchy. That crossmatch result, if it was actually performed, would be difficult to miss.

While distractions are part of the job (I used to work 3-11 by myself in a small lab as my own phleb), a tech with that much experience also should understand that one mistake in blood bank can have disasterous consequences.

[redwiner]

The patient is still okay, I really don't know how much blood was actually transfused.

The tech involved (did the crossmatch) is a friend (I'm not at the same hospital). They do realized the severity of the error, but my feeling is that if we are able to learn from ours/and others mistakes that it only makes a better tech.

I've worked with quite a few techs who just have no clue but have just been lucky enough not to make 'the big error' or simply it hasn't been caught.

[jhaig]

It usually only takes one close call to scare a blood banker into not letting a possible error happen again. My first year I drew a patient without checking their hospital wristband for a crossmatch. I had just started in the blood bank and an alert co-worker noticed the RBC to plasma ratio in the patient I drew wasn't even close to matching that of the person needing a transfusion. That mistake has made me a better blood banker and I definitely learned from it.

[redwiner]

well, they gave him the termination papers today. He asked if he could resign & the let him.

[janet]

That is awful that they wouldn't look it at as a first time error in 20 years! Your work ethic for years should account for something! :0(

[Eagle Eye]

I understand everyone's point...first tech making error in interpretation.....

but second tech wrote same reaction??? OK fine but that's why we have IS XM to detect ABO incompatibility. A blood bank tech. should know the importance of immediate spin crossmatch.

How can you not do a crossmatch? When you do not have a computer system, you have to be more careful and make sure you document the reaction at the time of reading it.

How do they prepare tag for the unit? You should have a system to check the card/results before preparing the tag or before dispensing the unit.

I think this was an error at my institution it would have a resulted in termination.(some time you may have to do it because of the pressure from upper management).

[jhaig]

That's too bad, but not unexpected. You can be the best blood banker in the world with a fantastic work ethic but one mistake or error in judgement can cost someone their life. That's just part of the responsibility thrust upon all of us when we became blood bankers.

By the way, did only one tech resign? Weren't there two involved? Just curious...

[geekay]

Hi there...

Was rather surprised to see the same mistake being repeated by the second technician in the blood grouping and typing....

It is very clear that he had adopted a "short cut" method in the technical procedures....

I believe in the fact that, in Blood Banking dictionary, the word "sorry" or "pardon" does not exist , especially when the mistake has to do with the technical procedures involving steps like "issue and transfusion".......

I remember my senior professors words...."we don't need people with "sixth sense" or "extra intelligence" in Blood Banking ! But we need to have people with "honesty" , "common sense" and "sincerity"....in our field...

Hope you agree with me ?

(If I had been in your position, I would have taken immediate steps to initialise computerisation in the Blood bank ! After all, "EXPERIENCE IS THE BEST TEACHER "

best wishes !

[clai01]

If the employees have not make significant error prior to this incident, then I don't think they should be fired, unless there's proof that they did not actually perform the testing and they claimed they did. Definitely needs to have documentation showing that the employees were counselled. In addition, re-training and competency should also be done on those employees involved.

But this is a serious error, the hospital should consider implementing a computer system for blood bank. I'm surprised that there are still hospitals without computer system. Let's be proactive here.

[huntilla]

Hope you agree with me ?

(If I had been in your position, I would have taken immediate steps to initialise computerisation in the Blood bank ! After all, "EXPERIENCE IS THE BEST TEACHER "

best wishes !

[John C. Staley]

Any one still wonder why there is a shortage of techs and no one wanting to come into the profession, especially Transfusion Medicine? When the pressure to pay ratio is as one sided as this occurrence shows, it's no wonder we are are a vanishing breed.

As long as humans are involved human error will occur. There is simply no getting around it. As long as negligence or wilfull misconduct can not be proven then we should give them the benefit of the doubt. No one has mentioned the work load these two were under. How many shifts/hours have they been working do to short staffing? There are too many factors we don't know but they all contribute to someone's ability to perform.

I am currently down 20% of my work force and when you only have 8 to start with that's significant. One night tech is working 11 on 3 off until someone can be hired and trained to be his opposite on a 7 on 7 off. Others are pulling extra shifts as well. I certainly hope nothing like described above happens and we do have some safety features built into our computer system to help prevent it but it could happen. To me that's an indication of over work and over stressed and something else needs to be done if possible but certainly not a reason to terminate anyone as long as gross negligence can not be proven.

This, to me, is a clear justification for computerization for the facility involved. A computer system will cost a fraction of the law suit and settlement.

[clai01]

Tech shortage does not just exist in Blood Bank. I agree the workload of those techs should be in consideration along with other factors, but at the same time, we are dealing with human lives here.

Implementing the gel system is a good option. It takes away the subjectivity. How about utilizing the IT department, ask them to develop a database using Microsoft Access to keep track of the patient ABO/Rh records if a full LIS system is out of the budget. Paper logs is definitely not a good method for record keeping.

[jhaig]

Shortages are everywhere, but I'm pretty sure a jury wouldn't want to hear about it. Hopefully this incident has moved computerization of the blood bank up the administration's 'to do' list.

There are so many factors to investigate in this case, but what is the bottom line? A patient had the potenitial to be killed and it may or may not have been caused by a short-cut in testing or erroneous results. There's no excuse for sloppy work, no matter how busy you get. Yes, I'm sure that there were issues involving staffing, overtime, extra hours, workload, etc. But you're dealing with real people, and had this patient died, do you think this patient's family members would have cared one bit about anything except that a tech's mistake led to their loved one's death? Put yourself in their shoes for a minute and see how you would feel.

Still, give the tech(s) a break until further investigation shows some type of wrong-doing or not.

[redwiner]

only the tech the second tech. I doubt anything happened to the first one.

[dstoever]

I am also curious, also, and what about Blood Bank fundamentals, results should be documented and interpreted while the tubes are in your hand. and, you look at the tubes and your interpretation before you toss the tubes. Distractions should not be an excuse to err. If we get distracted by anything, we should start over.

[Ellen Zeigler]

A error was made in typing a patient (no bb computer system). First tech had done Type & Screen. Reactions of ABO were written down correctly, but interpretation was not (Patient was B neg, type interp. as A neg). Following tech repeated type when doing the IS xmatch. Type interp. erorr was repeated by 2nd tech (next line on log sheet). IS xmatch apparently was not done, or not interpreted correctly. Patient was transfused.

This was a small lab, tech was working alone (also w/o a phleb, because someone had called in sick). They have been working for over 20 years without significant errors. Would you fire them?

Firing a tech does not look to the root cause of the error. Root cause analysis is required for your report to the FDA as the error was made in the blood bank. The tech in question may provide the most valuable insight into the cause. Punitive measures do not help develop a culture of improvement. Without a doubt, the error needs to be documented consistent with your facility [hr/laboratory] policy.

[Sara B]

The fact that the IS crossmatch was NOT noted as a 3 or 4+, just doesn't make sense. I think that is one point that really needs investigating. It just isn't possible, is it? So is the tech falsifying the record? Falsifying the record would certainly be grounds for firing. I've worked with and without a computer system over a number of years. The computer is only as good as the information put in it. We still need to always be engaged when working. I, too, have taken call and performed crossmatches in the wee hours of the morning when I was really tired (It's the pits to start over because you added Coombs at the wrong time!). You still are responsible to do that one last check - that one last IS that makes sure you didn't goof anything up.

[kph]

The second set of testing sounds like the proverbal "sink" testing. I can see counseling the first Tech and being more severe with the second Tech.

[John C. Staley]

Just a thought on the IS xm that has not been mentioned. How many of you have had old or immuncompromised patients who do not reverse type on immediate spin and would most likely have a compatible IS crossmatch with an incompatible unit? There is a lot to this scenerio that may never be known because of the way it was handled. While getting rid of the people may give the impression of "doing something" it seldom identifies, let alone, solves the problem.

Granted, this is a stretch but it is something that should have be determined if it was not. :raincloud

[Mabel Adams]

I wonder if the second tech forgot to put serum in the IS xm tube. The volume would have been low, but if she were distracted enough she might not have noticed it.

[redwiner]

The error was made in Gel, which may have contributed to the problem....since the reactions are "opposit" of those with tube.

I'm always rather amazed by supposed error free techs. Are they really error free, or they just have never been caught in their mistakes?

As I get older I rely much more upon my experience & instincts since there are so many more interuptions while working (phone calls, tube systems, alarms etc.) I can easily see thinking you did your saline crossmatch.

[heathervaught]

The second set of testing sounds like the proverbal "sink" testing. I can see counseling the first Tech and being more severe with the second Tech.

One of my former QA directors once told me "A second check is not necessarily the best check, and does not exempt the original person from doing the activity right in the first place".