The lab is presenting an inservice to  nursing on patient identification and proper labeling of specimens.  We are looking for a real world example of a bad patient outcome due to a mislabeled blood bank specimen.  As much as I hope you all say it never happens, does anyone have an example of such an occurrence?

My first thought was Coney Island Hospital in NY, but I'm not sure if that was a specimen labeling issue.  

horror story of MD drawing blood in the ED THEN labeling all the tubes in his pocket.  GI bleeder got 16 B+ rbcs and 20 B plasmas.  Then transferred to my hospital (tertiary care) - we game him a few ffps.  4 days after admit they wanted rbcs.  He tube typed as a B+ with many unagglutinated cells in the tubes.  These unagglutinated cells were O NEG - as was the patient.  His bili went from 2 to 31 in 16 hrs and he essentially hemolyzed to death. 

 

BB tech was fired at the originating hospital as that pt was in their card file as an O NEG.  Apparently pt was known throughout the county he lived in - hence he was transferred to us (in another county).  My boss said, "This was a dastardly deed!".  We turned them over to the FDA as we had not transfused rbcs.

Here's a link to the FDA data on transfusion-associated fatalities. I know of at least one death to which an ABO mismatch contributed.

 

http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/ReportaProblem/TransfusionDonationFatalities/ucm346639.htm

We had an OB nurse mislabel a specimen. We typed the patient as AB Pos and she was really O Pos. This happened just ONE MONTH after we implemented 2 blood types before giving type specific. So we caught the error when her second sample typed as O Pos.

Thank God we did not give her blood, and if we did we would've at least given her O cells with our new policy. As it was a near miss though, we still reported it to NYS, quality, etc. The nurse acted like it was no big deal because "I must have just grabbed the wrong label".

Terri

 

A most terrifying quote by your nurse!

We have had a few incients such as Terri's. A point you might make is that it doesn't have to be a blood bank specimen to have a bad outcome. The wrong person's coag, CBC, glucose, potassium or culture can kill you just as dead - and there's a heck of a lot more of them coming into the lab. Do you have any misidentified statistics to share, and try to improve? You can stress that they're also just the tip of an unknown iceberg. We only find the ones whose type has "changed" or who fail delta checks.

 

LABEL AT BEDSIDE!

 

Good luck.

Well, I had a mislabel that was caught, so there was no bad outcome, just an angry nurse. (this was > 10 years ago)  Nurse A claims to have drawn Bed 8 in ICU and uses BBID band.  Tube types as A Pos.  Luckily, we had a history on the patient, which was O Pos.  I called Nurse A, who claims she drew the right patient and refuses to redraw.  I offer to send up a phleb, which she also refuses.  Turns out she drew Bed 7, banded Bed 7, then a CNA saw the wrong band on Bed 7, removed it, and placed it on patient Bed 8 without Nurse A knowing about it.  Her refusal to redraw Bed 8 was overruled, and a lab phleb was sent to do the redraw.  In this case, history saved the patient.

 

2nd incident at another hospital: phleb draws and bands the patient.  We have no history.  This was before the push for 2nd draws.  Patient types as A Pos.  I get the blood ready and issue it.  The nurse immediately calls down and says she can't find the BBID band on the patient.  I ask the phleb to go back to the patient and show the nurse where she put the band.  Instead, the nurse comes back with the blood, and the phleb brings me a new sample and new BBID #'s for the patient.  This new sample types O Pos.  The phleb refuses to admit that she initially drew the wrong patient.  In this case, lack of a BBID band saved the patient. (yes, the phleb was soon terminated).  Nursing follows the policy, and the patient lives.

 

I have also had a few cases where the type and screen specimen was one type and the confirmation specimen was another.

There is a case reported by SHOT in the UK where there were two unknown patients in an urgent care facility. One patient was given A+ and deteriorated. As they were a small hospital they transferred the patient to another hospital where the laboratory noted a mixed field reaction in the A and D cells. They assumed the patient was showing a dual population due to flying squad in urgent care --they hadn't had flying squad-- and transfused more A+. Patient was O- and died. 

 

The second lesson is that assumption is the mother of all f&ck ups and always fully investigate a dual population.

 

I have trialed a solid phase technology that works similar to a PB/IM/glandular fever test - I rejected because in this scenario it would ahve grouped the patient incorrectly with know knowledge of dual population.

 SHOT have some case studies

 

http://www.shotuk.org/wp-content/uploads/Cases-from-the-2013-SHOT-Report-v-1-1.pdf

 

And clinical lessons

 

http://www.shotuk.org/wp-content/uploads/66444-PR_72511-SHOT-Clinical-Lessons_28-01-p1-LR-PS.pdf

David, I am surprised he lasted that long.

 

horror story of MD drawing blood in the ED THEN labeling all the tubes in his pocket.  GI bleeder got 16 B+ rbcs and 20 B plasmas.  Then transferred to my hospital (tertiary care) - we game him a few ffps.  4 days after admit they wanted rbcs.  He tube typed as a B+ with many unagglutinated cells in the tubes.  These unagglutinated cells were O NEG - as was the patient.  His bili went from 2 to 31 in 16 hrs and he essentially hemolyzed to death. 

 

BB tech was fired at the originating hospital as that pt was in their card file as an O NEG.  Apparently pt was known throughout the county he lived in - hence he was transferred to us (in another county).  My boss said, "This was a dastardly deed!".  We turned them over to the FDA as we had not transfused rbcs.

There is a good video on YouTube done by Hugh Laurie  - "The Strange Case of Penny Allison".  It humorously present a host of potential transfusion/labeling errors.  Maybe humor is not what you want, but it does get the point across!

Mind you, although I agree totally, it DOES, notwithstanding, show the layperson's view of the "scientist">

It's hilarious! I made my other half watch it and he actually enjoyed it too

 

There's some great resources on here for medics/nurses and it has interactive case studies too and there are also lab units available. It's NHS Scotland based but it seems anyone can register...

 

http://www.learnbloodtransfusion.org.uk/

The piece has appeal to clinicians and non-clinicians alike, I think.  Don't know how much the actors really understand about Lab work, but Hugh Laurie is a great comic actor. Imelda Staunton is pretty good too.

 

Scott

As I understand it, Hugh Laurie did spend some time getting to know things prior to filming - but that does not mean that I would be happy to have him cross-match for me!!!!!!!!!!!!!!!