How many mistakes is acceptable?

[Malcolm Needs ☆]

Going back to the original situation...oh my gosh. Working in the transfusion medicine field requires a certain level of accountibility. It sounds like all the regular channels to help improve the situation from the regular employee's part have been done. How frustrating.

Tracking and trending of even small oops! and near misses can really give a better picture how a department is running. It's too bad the big ones (like issuing incompatible blood) are being missed & swept under the table. Obviously this original situation presented is not doing well.

As an employee, I would leave if possible. Working for an employer that doesn't share the same morals of quality can be the wrong fit. Asking the employee to do another person's job (event reporting, tracking everyone's mistakes) can create a really negative work environment. I would leave lots of documentation on the exit interview.

I can see exactly from where you are coming kathL, but I think it is very hard that the innocent party should be the one to lose their position - but I do see from where you are coming.

:(:redface::(

[Kellpos]

Why wait for another event, and lawsuits - just fire her!

[rravkin@aol.com]

If I may say with respect to this situation it seems that poor management is begetting poor staff. One hinges off the other and it will always be this way. This problem tech was retrained by a manager that knows little of blood bank. How much more proficient was the problem tech suposed to be. Now this tech avoids more complex work probably because they do not have a good understanding of the work. Cuple that with an apparent lack of integrity and we have the making of a poor reputaion for all of us in the field. This tech needs to lose the part that promotes a lack of integrity and be properly educated about the work that they are responsible for and the effect on patient outcome. But with an apparent lack of proper education and the persons to deliver it this tech seems destined for failure and unfortunately her failure has the potential to be everyones in the eyes of persons outside the feild.

[Fluffy agglutinates]

I've been following this thread with interest & I do find the conduct of the staff member concerned very alarming! They are showing blatant disregard for patient safety. I know mistakes can happen to anyone but most are preventable and as for falsifying results - that cannot be justified ever.

Over here in the UK in order to perform this sort of work you need to be a HPC registered biomedical scientist (Health Professions Council). Once you are registered you become 'public property' & have professional standards & responsibilities to uphold. They have a complaints system which anyone can access & use. See link for examples http://www.hpc-uk.org/complaints/hearings/ . The HPC has the power to suspend/ reinstate/ strike-off or restrict your scope of practice. You wouldn't be able to work in the profession again if struck-off.

Any employer can also check the registration status of any employee at any time (it will tell you if they are under investigation/ suspended/ struck-off etc).

We are registered for 2 years at a time during which we are expected to undertake 'Continuous Professional Development'. At the end of each 2 year time-frame ~5-10% of registrants will be called upon randomly to prove they have done this. Re-registration is mainly taken on 'good faith' given the audit outcome. Each registrant signs a binding document stating they have upheld the expected standards & CPD (& will continue to do so) in order to re-register. We pay for it too!

I think it is a very good scheme & certainly makes you more responsible for your own actions!

This system allows any concern over individual staff conduct to be raised & investigated independently by the HPC. For your person in question I wouldn't hesistate to report them over if working over here.

Is there nothing similar in the US? I know some other posters have asked if the lab is AABB accredited - do they have any power?

[Malcolm Needs ☆]

I've never thought of myself as a piece of "public property" before.

Gosh, the general public don't realise how lucky they are!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! (OR NOT).

:bow::bow:

[Fluffy agglutinates]

So, do you see yourself as a 'listed building' or 'site of special scientific interest'?

[Malcolm Needs ☆]

So, do you see yourself as a 'listed building' or 'site of special scientific interest'?

More of a condemned slum building, destined to be demolished in the very near future to make way for a more modern structure all together!!!!!!!!!!!!!!!

:o:o:o:o

[adiescast]

Come now, surely you can make the register of historic buildings!

[Malcolm Needs ☆]

Come now, surely you can make the register of historic buildings!

Well, I am built like a brick out-house!

:o:o:o:o

[rescyth]

We got similar problems but at least yours is a tech and ours is just self proclaimed. Trust me...our lab is more screwed up than yours. Did the same thing even went beyond HR but did something happened? nooooo...

[bbbirder]

I believe that all accrediting agencies (CAP, Joint Commission, etc.) require their phone number/e-mail address for reporting safety concerns to be posted in the lab.

Please report this situation ASAP.

Let us know how it turns out.

[jlemmons]

We had a situation where the nursing staff were misidentifying patients on an ongoing basis and nursing would not do anything about it. One of our techs reported it to CAP and I can tell you that our senior people were very unhappy. They were required to show documentation about the situation. CAP is probably your best bet and/or JCAHO. Both of these agencies take these types of errors very serioiusly.

[L106]

We had a situation where the nursing staff were misidentifying patients on an ongoing basis and nursing would not do anything about it. One of our techs reported it to CAP and I can tell you that our senior people were very unhappy. They were required to show documentation about the situation. CAP is probably your best bet and/or JCAHO. Both of these agencies take these types of errors very serioiusly.

Sorry if it caused "trouble", but kudos for your tech for taking action to improve patient safety!

[Eoin]

A Quality Management System for Bloodbanks (like in UK, NATA in Oz or ISO15189 in Ireland (and elsewhere) sounds like an imperative. This gives the mechanism for reporting non-conformaties and is easily trended to find if errors are systemic (i.e. SOP needs changing) or individual. Gives you all the ammunition you will need. This can be fed into Best Practice or HR or whoever the Risk Managers are in your hospital - no action could result in a very costly litigation against the hospital (and all involved probably).

Cheers

Eoin

[jcdayaz]

THIS THREAD IS HORRIFYING TO ME! I have never heard of such mistakes being made by the same Blood Bank Tech repeatedly. We all make mistakes, each and every one of us has--INCLUDING ME! But the situation you describe here is absurd.

Go as high as you need to go to get this person OUT of the Blood Bank. CAP, FDA, Joint Commission, CONTACT THEM ALL! You might not be very popular with your co-workers if they find out, but you will potentially be saving someone's life. If I were in your shoes (Thank goodness I'm not), I would stop at nothing to get this person out! It sounds like you have exhausted your in-hospital resources, time to go further and higher up the authority chain.

This Tech is going to kill someone.

And, yes, the wrong blood type issued to the wrong patient is an FDA reportable event. Whether or not it was actually transfused...just issuing it was a reportable event. I believe (someone please correct me if I'm wrong) the situation you described about the E,c patient is also a reportable event.

I do not envy the situation you are in.

[Brenda K Hutson]

FDA Reportable Errors may be the least of your worries should your Hospital choose to retain this person! They would not have even gotten past an interview with me in that I give a "basic" written test to applicants who will work in my dept. (whether in the Blood Bank only, or as a Generalist on any shift). You would be shocked how many people will say in an interview, "oh yes, I know Blood Banking and have experience," and yet they cannot even tell you which blood types of FFP are compatible for given patient blood types! Best to weed them out right away. If they did somehow make it through the interview and test, I would have tolerated very little of your experience and made it easy on myself by getting rid of this person doing the probation period. But none of that helps you now with this person. Since it sounds like that did not happen, I am still honestly shocked that your Hospital would "want" to retain this person. She is a HUGE liability! HR depts. often worry about been sued if they fire someone. If I were your HR dept., I would worry more about being sued by the family of the patient this person is going to harm or kill if they are allowed to continue. Seriously!

I agree with many of the suggestions of others also. It sounds like you are documenting (or at least tracking; I would encourage you to make sure everything is documented) all of the errors but it sounds as though your Management does not care. I do not believe it is just because the Management does not know Blood Banking. First of all, a Manager should not be "over" Blood Bank if they have such a poor knowledge that they do not understand the ramifications of these serious errors.

I appreciate Malcolm's comments with regard to mistakes, and how people respond to them. I have always said that I do not want anyone working in my dept. who does not "feel bad" when they have made an error because every conscientious Blood Banker I have ever worked with, always feel bad when they make errors; even minor ones. And yes, these do tend to be the people who will try to cover-up, minimize, deny, blame, etc. when confronted with an error. Anyone with those "qualities" has no business in the Blood Bank (or any area of the Lab for that matter).

Brenda Hutson, CLS(ASCP)SBB

[jcdayaz]

Very well said, Brenda!

I once almost made a HUGE error(in my eyes)...I caught it before it left the department, but I was then so upset I went to the restroom and threw up! My supervisor at the time told me to calm down, that it is only a "mistake" if it leaves the blood bank. WRONG!!!!!! I could go on and on....but I won't.

We are all only human. It is what it is. But to not recognize the potential of patient harm by making errors in the blood bank--and the lab in general--is not okay.

[tricore]

bronxbomber - we haven't heard from you. Has the situation been addressed/resolved?

I have often thought while reading this thread that it would be an excellent resource for someone writing a management or ethics paper.

[jcdayaz]

Sorry if it caused "trouble", but kudos for your tech for taking action to improve patient safety!

You betcha! Sometimes you have to do what you have to do!

Apparently this particular nursing floor was drawing their morning run, lining all specimens up on the counter at the nurses' station, and THEN labeling them. Against hospital policy, nursing policy, phlebotomy policy....etc etc to not label a specimen at the bedside immediately after collection. Complaints, reports to management, etc went unrecognized. Thus the CAP/Joint Commission report.

The "situation" got resolved quite promptly.

[LaraT23]

I have often wished that accountability and personal responsibility were teachable things. That we could force upon employees the drive to do only their best at all times. I am often shocked at what other people can live with pertaining to their job performance or lack thereof. It is unfortunate that your direct supervisor is without a backbone. Had this been me, the tech would have been removed long ago, or I would have been fired. I absolutely will not tolerate that. To the point that just a year ago I had to remove a 35 year employee from my department because she mislabled and missed an Anti-E on a patient. A unit was very close to being issued, but another tech pulled the antibody screens out and noticed the one patient was labeled twice. The removed employee remains a very dear friend who was very understanding because she has a very high level of person responsibility and patient concern.

[adiescast]

The removed employee remains a very dear friend who was very understanding because she has a very high level of person responsibility and patient concern.

Kudos to you for handling it in such a way as to maintain the dignity of the person you had to remove. That is another piece of the puzzle that managers struggle with when this sort of thing has to be dealt with.

[Eagle Eye]

As a manager/supervisor, we must make sure we look at each error same way regardless of the person involved. we can not look at tjhe error with any bias. If yuo want to creat a department where yiu want to have a respect from every one, do not look at any one with the eye of...I like this person, i don't like this person etc.

I think this is the most important thing we have to learn as a manager and....YES some time it is difficult but if you are treating everyone equally, no one will mind you finding their errors.

[L106]

Very well said, Brenda!

I once almost made a HUGE error(in my eyes)...I caught it before it left the department, but I was then so upset I went to the restroom and threw up! My supervisor at the time told me to calm down, that it is only a "mistake" if it leaves the blood bank. WRONG!!!!!! I could go on and on....but I won't.

We are all only human. It is what it is. But to not recognize the potential of patient harm by making errors in the blood bank--and the lab in general--is not okay.

I understand what you are saying and how you felt about this situation. And it sounds like you were further upset by your supervisor's response ("it's only a mistake if it leaves the blood bank.") When I have had to deal with a staff member who has made a serious mistake/error, I'm glad to see them upset with themselves. However, when it's time to calm down and "get back on the horse" (ie: regain their confidence and function well again), I usually give them my speech to the effect:

"I'm sorry you made this mistake/error, and it should not have happened. Fortunately, no harm came to the patient this time. Therefore, I look at this "near-miss" as a "blessing in disguise." This mistake should make you more aware of what you need to do to prevent making this error again in the future (which might result in serious harm to the patient, your termination, etc.)"

By the way, we once had a staff tech who was "bright", but made more than one technical error and just didn't seem "focused" on his work. We terminated him, and it turned out to be the best favor we could have done for him. He then entered and completed dentistry school, apparently has done well, and I'm sure is much happier than he ever would have been as a laboratorian.

[jcdayaz]

I understand what you are saying and how you felt about this situation. And it sounds like you were further upset by your supervisor's response ("it's only a mistake if it leaves the blood bank.") When I have had to deal with a staff member who has made a serious mistake/error, I'm glad to see them upset with themselves. However, when it's time to calm down and "get back on the horse" (ie: regain their confidence and function well again), I usually give them my speech to the effect:

"I'm sorry you made this mistake/error, and it should not have happened. Fortunately, no harm came to the patient this time. Therefore, I look at this "near-miss" as a "blessing in disguise." This mistake should make you more aware of what you need to do to prevent making this error again in the future (which might result in serious harm to the patient, your termination, etc.)"

By the way, we once had a staff tech who was "bright", but made more than one technical error and just didn't seem "focused" on his work. We terminated him, and it turned out to be the best favor we could have done for him. He then entered and completed dentistry school, apparently has done well, and I'm sure is much happier than he ever would have been as a laboratorian.

Yep...NEVER happened again. I will say my description of a "huge error" is probably different than other Techs. I expect perfection..each and every time from myself. I set up O neg units on an O pos patient when we were EXTREMELY short on O negs.

UGGH!

[Malcolm Needs ☆]

Yep...NEVER happened again. I will say my description of a "huge error" is probably different than other Techs. I expect perfection..each and every time from myself. I set up O neg units on an O pos patient when we were EXTREMELY short on O negs.

UGGH!

But, that having been said, I repeat that a laboratory worker who says that they have never made a mistake is a BIG accident waiting to happen. It is the attitude of the person after they make the mistake that is of paramount importance, in my opinion.

:eek: