We recently had a nurse call to say that the unit of blood she received was visibly bloody on both sides of the unit.  Blood was smeared on both the unit label and the crossmatch compatibility label.  The courier brought it to her and she laid it down in the patient's room while she went to attend to another patient, and when she returned and picked up the unit, it was bloody.  She checked it for leaks and, finding none, started the transfusion "because the patient needed the blood."  (She is Type A Neg with an anti-Fya and a 6 gram hgb.)  She then called the courier who brought her the blood and the courier said she didn't have any blood on her and didn't see any blood on the unit when she picked it up.  The nurse then contacted our Employee Health nurse who told her to call the blood bank.  I was the individual who checked out the blood and told the nurse that it did not leave the blood bank in that condition.

Any thoughts on this situation?  I want to scream NO! NO! NO! but need some ammo for our risk manager.  By the way, each manager concluded that their employee did nothing wrong and "Standard of Care" was met.

 

Had the nurse "spiked" the unit prior to laying it down?  Was there any other possible source for the blood?  I'm sure you asked these questions initially but I felt inclined to put them out there.  One more question, how bloody was bloody?  This is indeed and odd situation!  

Whatever the cause, I do not think the unit should have been hung in that condition.  I would think that, at the least, the RN hanging the unit would have checked with the BB or a supervisor first.

Scott

Sounds like a leaky segment.   Do you get the bag back so you could investigate?   I would document  this incident as a safety event.  

 

Definitely report as a safety event. I would agree with a leaky segment or a punctured bag when the unit was spiked. Should have been checked by blood bank prior to transfusion.

It was documented as a safety event, and no, I didn't get the unit back so I can't say how bloody.  The nurse called me after she transfused the unit and had discarded the bag.  I didn't think about her spiking the unit prior to laying it down.  I have had leaking segments before, but I pulled the segs just prior to issue and would think that I would have noticed blood on my hands or the checkout counter if that had been the case.  I do handle and mix them while inspecting them at issue.  She put in the incident that the labels were bloody when she got the unit from the courier, but that it looked dried and she just thought it was odd.  Later when she picked it up to transfuse it she had blood on her gloves.  If it leaked in transit, I would think the courier would have had blood on her hands, and she did not.

I suppose depending on how the unit was held by the courier, a leaky segment could indeed be the culprit.

Scott