An Easy Way to Save a Life... or How to Not Kill Somebody

Music in My Heart

A number of people read my post a while back about a serious error in which I was involved... and I was humbled and grateful for the outpouring of support and encouragement that I received here (and from a number of docs and nurses at work).

I'm still working and still being placed in critical roles so I've finally concluded that the system has forgiven me my role in the transgression.

I'd like to think that part of that forgiveness derives from the recognition that I am a pretty solid nurse who's had my share of good catches, saves, and atta-boys... just like the one I'm about to share.

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I was floating in the department when a GI bleeder came in... a 50-something going on 70-something lady bleeding from the top and bottom... yellow skin, distended belly... a liver that's filtered way more booze than it should have... festering wounds... and veins that have seen too many needles...

But hemodynamically stable...

So we tag-team the patient, line her up and wait for labs and type results...

H/H comes back at 5.5/15.3... and platelets at 69. Doc wants to begin transfusing immediately... I tell him to initiate the massive transfusion protocol which gets us a pack of O neg PRBCs, platelets, and FFP to begin with while we're waiting on matched units to become available... Doc gets on the phone with the bank and then tells me that (a) the screen is done, (b) the patient is already in the system, and © the patient's got some antigens that require special units... but to send a runner to fetch the MTP pack.

The patient has formally become mine but my peeps are all staying involved because she's proving to be a busy one. So the cooler arrives... While my peeps are setting up for the transfusion, I take a look to see what we've got... 3 units of O pos, 1 unit of O neg, and 2 units of A pos...

So I'm looking at the blood and thinking, "well, she's in the system and I know there's something special about the units she needs and the doc's been on the line with them... they must have sent the A pos to get us started and the O units as backup while they're doing the cross-matching." Of course, that's atypical because we typically only give O until we've got matched units... and they've never sent me a pack of mixed types...

I tell my guys to hold on pulling the transfusion trigger and call the bank... as I explain myself the CLS says, "no, there's no A... the patient is O pos." I assure her that I'm looking at two units of A along with the O units. She calls out to her peeps, "You guys didn't send A units did you?" and then to me... "OMG... don't give them!!! She's O, not A... you need to send them back right now." I assure her that it's all good... that I'm the one holding the blood... and that I will be initiating the transfusion...

We go through each unit one by one, by unit number, and end isolating the two A units and the O neg (d/t to the antigen thing)... and confirm again, number by number, which units are OK for transfusion.

The wrong units never came close to the patient. The attending came by and said, "Hey, you just saved her life." I replied, "she was stable the whole time and you got one of the lines..." He said, "No, I'm talking about the blood... you saved her life by not killing her with the wrong blood type."

The moral of the story is... slow down and check your stuff... no system is 100% and we as nurses are the final door through which the reaper has to pass to get to the patient...

If anything ever seems not right, check it out until you're satisfied. Never assume that the system is working nor that someone else hasn't screwed up.

Thanks for reading and remember... Do No Harm...

ps... I also like the old Smoky the Bear admonition... "Only you..."