Barriers to understanding

[Auntie-D]

Need to rant!

 

I had a tricky one yesterday - massive obstetric haemorrhage on an ANeg patient. No group on the patient so AB plasma issued (both rhesus postive and negative), A positive stock platelets given and ONeg flying squad units.

 

It was a total mess!

 

Firstly they came to the lab wanting units without even requesting them, the sample was still in the centrifuge so flying squad units were issued. It was at this point that the lab person asked theaters if they were wanting to initiate the massive haemorhage policy. They did. The theater person was sent away with two units of flying squad blood and told we would phone when we had blood available. The FFP was put into thaw and stock platelets ordered from our sister lab. By the time the sample was on the analyser and had 8 minutes to go. 

 

The theater person turned up and requested 4 blood, 4 FFP and 1 platelets on the baby and had brought down the notes for the baby. We informed them that we hadn't even had a sample from the baby but could take the neonatal flying squad if needed. Rang theaters and they informed us it was the MHP pack for the mother not the baby! The person collecting the products hadnt actually brought the proper noted with the transfusion request, but an addressograph sticker... Theater person was sent away for the correct notes and told the blood would be ready when they returned.

 

They returned and took the blood and FFP - left the FFP paperwork so obviously didn't do the proper checks on it. Called them back to collect the paperwork and gave them the platelets to which was now ready.

 

Next they were on the phone complaining that the platelets were Rh pos. We told that this was fine and we would issue anti-D and just to transfuse. We issued the anti-D and another theater person came down to collect it. When they arrived they didn't have any patient identifiers at all so was sent to collect the notes. Their response was 'why do I need to check again if my colleague as done all the checks already?'. Staff member was reminded it was both national and local policy and the reasons for this. When she returned she was rude and huffy

 

Half an hour after the platelets were collected we received another call claiming they couldn't find the product number on the anti-D to complete the checks (they were looking at the lot number, not the unique identifier). They informed us at that point that they 'couldn't issue the platelets until the anti-D had been given'. They were informed that they had 72 hours to give the anti-D and they shouldn't be withholding platelets in a MHP situation!

 

Grief - imagine if we had run out of rh neg blood and had to issue rh pos?!?! We only had 4 units left at this point

 

Anyway they gave the platelets and anti-D.

 

A few hours later we received another call to say that they had found the baby's cord blood but the person who took it had left and they hadn't filled in a form. My colleague (wrongly) told them to send the sample with a form signed by her and we would accept it.

 

The sample arrived and was labelled as 'baby of YYYYY' when it was baby of XXXXX.

 

Could any more go wrong?? And I was the one who had to fill in the incident form

 

The staff involved are being retrained and competency assessed and the transfusion practitioner is going to do a talk about 'suitable' instead of 'compatible' in an emergency situation and issue firm guidelines.

 

I left with a headaches that day

 

Why can people just not follow policy

[SMILLER]

Sounds like you and the rest of the Lab staff did a pretty good job here though!

Scott

[David Saikin]

I have found that most of the time when it hits the fan it makes a horrible mess.  No matter how many drills, practice events - whatever, when it is the real deal it is only the blood bankers that really keep their cool.  I have been cursed at, sworn at, threatened with bodily harm - the direct care givers don't know or are just too crazily busy to want to understand the BB and policy (even if they are the ones who wrote the policy).  All we can do is what we know is correct and safe - we also won't let the pt bleed to death.

 

As Walt Whitman wrote:  "If you can keep your head when all about you others are losing theirs and blaming it on you."

 

Good job Auntie (why am I not surprised).

[Auntie-D]

I spoke to the theater sister who was still uncomfortable about giving rh pos platelets - I explained that in a massive haemorrhage situation the aim was to stop the patients exanguinating, not to prevent an antibody developing. That if the patient developed an antibody it would only ever be a problem if she had a rh pos baby in a future pregnancy - it would not pose a transfusion problem as we would transfuse Rh Neg units anyway. That if the patient did have an antibody, and was massively bleeding then we may have to transfuse incompatible blood just to maintain fluid volume - that this would be inconsequential as the reaction would be occuring on theater floor, and we could deal with a delayed transfusion reaction a few days down the line when the patient was recovering.

 

She still claimed it went against everything her gut told her. Both I, and the transfusion practitioner, told her that her gut reaction should be to prevent the patient from bleeding out by ensuring that the suitable blood was transfused in time - that ABO was the only thing to worry about in a MHP situation.

 

I think she was still uncomfortable...

[CMCDCHI]

Sounds like you did well in the middle of a very trying situation.  I always try to remember that the people actually in the room with the patient are in the midst of crisis and doing their best.  After a massive transfusion situation recently, the OR returned some unused products.  The platelet was returned on ice, and our brand new (expensive) cooler was broken.  

 

It can be so frustrating.  We just lost a mother in L&D last week.  Most likely blood products would not have helped, but the emergency issue blood sat down in the lab for longer than it should have because they were expecting us to bring it to them, when it is the policy that someone from the unit comes to pick it up.  

 

Hopefully some important lessons will be passed on in the spirit of continuous improvement.

[Dr. Pepper]

All this just reinforces my opinion that one should never, never, ever

 get sick, because then you can get treated and all sorts of bad things can happen!

[BankerGirl]

This all sounds VERY familiar!

[BankerGirl]

All this just reinforces my opinion that one should never, never, ever

 get sick, because then you can get treated and all sorts of bad things can happen!

My microbiology supervisor just told me this morning that if she ever needs blood on second or third shift, her husband has instructions to call me at home.

[SMILLER]

I know you are all joking, but I can't help but mention that if I ever really did not trust my own employer to operate my Lab appropriately, I would start looking for another employer.  Whether it is me or anyone else being mistreated, either due to inadequate resources or training, makes no difference.

[EDibble]

I know you are all joking, but I can't help but mention that if I ever really did not trust my own employer to operate my Lab appropriately, I would start looking for another employer.  Whether it is me or anyone else being mistreated, either due to inadequate resources or training, makes no difference.

It is not the lab staff I don't trust, it is other people.

[tricore]

This was told to me when I was a med tech student (in ancient times): Better a live patient than a dead "pure" one.

Still holds.

[Dr. Pepper]

I had a routine diagnostic procedure done the other day. A 40-year RN missed my sewer pipe vein trying to start an IV. Later that evening I scratched at some irritation on my chest and found they had left 3 electrode patches on me. Not huge things, but this was done at a local hospital that fancies itself the mecca of medicine in the state, if not the world and universe. We make pretty well-informed patients (thank God); unfortunately, the average patient off the street does not have that advantage.

[Auntie-D]

Dr Pepper - I went for my booking bloods done when I found out I was pregnant. The first error they made was labelling my family originne questionairre for haemoglobinopathy screening as 'low risk' due to my apparent caucasian appearance. We have a family history of both alpha and beta thalassaemia! I pointed out the potential consequences of this very serious oversight. The second error they made was taking my G&S sample and then trying to send me away with the form and sample unlabelled on the bench. I pointed out to her that the labelling errors (10-15% currently) would be nearly eliminated if they would fill in the details from what the patient is telling them - guaranteed correct spelling of name and correct DOB.

[Dr. Pepper]

And did they politely thank you Auntie, and grace you with a glacial smile?

[Auntie-D]

And did they politely thank you Auntie, and grace you with a glacial smile?

 

Bemused look and 'Really?' *sighs*

[BankerGirl]

When I became pregnant with my first child it was discovered that I had developed an anti-K from a previous blood transfusion.  After I returned to work I discovered that the blood banker doing my type and screen forgot to crossmatch antigen negative units.  Now granted, if I had needed blood, the odds were in my favor for receiving K neg units, but that didn't seem to work out too well with the first two units I received. With Baby #2 I reminded them to crossmatch the units this time. 

[EDibble]

Forgot???? That is inexcusable.

[Eoin]

What happened to checking Ab history??? I know that lots can go wayward outside the lab - but inside a BB lab - should be as in SOPs! Mind you - if something goes wrong with specs or results Sod's Law applies and it is often one of the hosp staff specs or results - maybe the case of being TOOOOO careful!

[Dr. Pepper]

What happened to checking Ab history??? I know that lots can go wayward outside the lab - but inside a BB lab - should be as in SOPs! Mind you - if something goes wrong with specs or results Sod's Law applies and it is often one of the hosp staff specs or results - maybe the case of being TOOOOO careful!

Our lab (not the BB of course) messed up with our hospitals president's auntie's spec one time, had to get her redrawn. Oops.

[DCeDCe]

Flying squad?? Theater person?? I am lost by your lingo. Please explain.....

[Eoin]

This side of the pond O Negs (Typed as CDE Neg, possibly plus Kell Neg) which are held as emergency blood have traditionally been described as "Flying Squad" blood (maybe because people fly around madly with it in an emergency hemorrhage situation).

Theater person would apply to anyone coming from theatre (or theater as you spell it) to collect units (could be a nurse, theatre assistant or theatre porter in our case). Hope this helps with the "Lost in Translation" DCeDCe.

 

Cheers

Eoin

Edited September 10, 2015 by Eoin

[Sandy L]

And from west of the pond, I would assume that the theater or theatre is the operating room/surgery?  It's so interesting to see the different names we all have for the same thing/

[Eoin]

Ah yes, it is indeed the O.R.  We don't have the time to sit down and watch a play at the theatre (which is also theatre - same as OR, but with actors instead) - Mind you some of our surgeons are actors!!!!!

 

What an interesting language English is. 

Cheers

Eoin

Edited September 18, 2015 by Eoin

[Kellar]

I have heard similar stories many times and am a bit disheartened that the narrative never changes.  Do you think there would be value in having a person from the transfusion service "issued" along with the first units when a mass hemorrhage plan is activated?  I imagine this person acting as a liaison/translator/educator/helping hand/cool head with respect to transfusion.  I can imagine that when things are going badly in OR or Emergency, all the little details that are important for transfusion are NOT priority in the minds of those involved in direct treatment of the patient.  Perhaps the TM service could provide a little assistance. 

 

From a broader perspective, as lab professionals, are we too attached to our labs? Whether it is true or not, we tend to feel that we are undervalued and under appreciated, but at the same time we stay hidden away in the lab making demands that seem like nit picking to those without training in laboratory practices.  I think, traditionally, that pathologists have been the link between lab professionals and primary care providers (i.e. physicians and nurses).  But pathologists can be very busy with their many other duties, is there a place for non-pathologist lab professionals to step in make more direct connections with primary care providers?  

[Dr. Pepper]

I have heard similar stories many times and am a bit disheartened that the narrative never changes.  Do you think there would be value in having a person from the transfusion service "issued" along with the first units when a mass hemorrhage plan is activated?  I imagine this person acting as a liaison/translator/educator/helping hand/cool head with respect to transfusion.  I can imagine that when things are going badly in OR or Emergency, all the little details that are important for transfusion are NOT priority in the minds of those involved in direct treatment of the patient.  Perhaps the TM service could provide a little assistance. 

 

From a broader perspective, as lab professionals, are we too attached to our labs? Whether it is true or not, we tend to feel that we are undervalued and under appreciated, but at the same time we stay hidden away in the lab making demands that seem like nit picking to those without training in laboratory practices.  I think, traditionally, that pathologists have been the link between lab professionals and primary care providers (i.e. physicians and nurses).  But pathologists can be very busy with their many other duties, is there a place for non-pathologist lab professionals to step in make more direct connections with primary care providers?  

You could always marry a nurse.