Gave pt the WRONG blood! - page 2

It makes me sick to my stomach just to type this. Due to an error by the lab pre-op I transfused 8 UNITS of the wrong PRBC's into a patient! She had MULTIPLE other problems post-op but this sure... Read More

  1. by   codebluechic
    You're probably right, but regardless of who made the error it was the docs choice to inform the family. That's why I gave him credit. If it were my family member I would want to know everything.
    Thanks again to everyone for the replies.
  2. by   Sue D
    How awful for you. I was once involved in a similar error when our in-house haematology lab got two patients with the same name confused. Like you we acted in good faith, beleiving that we were acting in the patient's best interests. Don't feel bad, the fault wasn't yours.
  3. by   P_RN
    About 3 years ago our hospital in all its wisdom decided that the nurses were going to be trained in phlebotomy. We had a phlebotomist for only the am lab draws and they would stay until about 1pm. Well it DID increase our workload immensely but at the same time it gave me more insight on how the process works.

    We used the Baxter-Fenwall system of blood ID wristbands and stickers.
    You had to hand write the name and hospital number, the date/time and your initials on the wristband. You then drew the blood, tore off the top layer of the nameband and put it on the tube along with a sticker from the band to put on the request slip. To me that was the closest thing to a perfect system there could be. Nothing left the patients side until the blood was labeled and the patient ID'd.

    You then had to have a signed consent of the patient to give the blood. When it came time to request the blood, you had to have the name, number etc and you had to have 2 licensed people at the bedside to check the blood. If the patient did not have on the Fenwall band then the blood went back to the blood bank and the whole process had to be repeated. It relies of course on no shortcuts being taken.

    Anybody else have a different system where they work?
    _____
    Addendum: this is a policy VERY similar to what ours was. I have no connection with this facility and got this using GOOGLE, but it really worked for us at my place.
    http://medweb.uhcolorado.edu/PnPDocs..._C/c059699.htm

    [ June 03, 2001: Message edited by: P_RN ]
  4. by   codebluechic
    P RN, we have no system like that in our hospital. Maybe if we had...
    I will bring up the possibilty of initiating that or something similar, thanks.
  5. by   oramar
    Here is more of the kind of phoney baloney that drove me away from the bedside. One of the staff nurses I worked with was observed hanging blood on a patient without checking the arm band by a nursing instructor. The nursing instructor also happened to be the wife of a prominent physican who had a lot of clout at the hospital. The instructor went up and raised hell with the DON. They gave the nurse a two month working suspension. Yes I said WORKING SUSPENSION. She admitted to me she was wrong but she was also was perfectly aware that the punishment was more based on who had seen the mistake than the actual mistake. This system of punishing people based on how big of stink is made about the mistake is standard proceedure through out the health care system. Here is what should have been done. They should have looked at the policy and proceedure book. If they had they would have realized our blood policy was based on a special blood banding system that the hospital stop purchasing because it was to expensive. This left nurses on their own with no set policy to follow. I noticed it resulted in a lot of people doing a lot of different things, some of them dangerous. Instead of owning up to the policy problem and explaining that laxity in updating the proceedure manual was at least contributing to laxity at the bedside, the nurse was suspended. (Oh, by the way a very quite manual update consisting of a supervisor sliping a new policy into the manual was done) Over my years as a nurse I have seen stuff like this again and again and it is the reason I have such a deep dislike of bossess and academians.
  6. by   RN1963
    Originally posted by P_RN:
    <STRONG>About 3 years ago our hospital in all its wisdom decided that the nurses were going to be trained in phlebotomy. We had a phlebotomist for only the am lab draws and they would stay until about 1pm. Well it DID increase our workload immensely but at the same time it gave me more insight on how the process works.

    We used the Baxter-Fenwall system of blood ID wristbands and stickers.
    You had to hand write the name and hospital number, the date/time and your initials on the wristband. You then drew the blood, tore off the top layer of the nameband and put it on the tube along with a sticker from the band to put on the request slip. To me that was the closest thing to a perfect system there could be. Nothing left the patients side until the blood was labeled and the patient ID'd.

    You then had to have a signed consent of the patient to give the blood. When it came time to request the blood, you had to have the name, number etc and you had to have 2 licensed people at the bedside to check the blood. If the patient did not have on the Fenwall band then the blood went back to the blood bank and the whole process had to be repeated. It relies of course on no shortcuts being taken.

    Anybody else have a different system where they work?
    _____
    Addendum: this is a policy VERY similar to what ours was. I have no connection with this facility and got this using GOOGLE, but it really worked for us at my place.
    http://medweb.uhcolorado.edu/PnPDocs..._C/c059699.htm

    [ June 03, 2001: Message edited by: P_RN ]</STRONG>
  7. by   RN1963
    Originally posted by P_RN:
    <STRONG>About 3 years ago our hospital in all its wisdom decided that the nurses were going to be trained in phlebotomy. We had a phlebotomist for only the am lab draws and they would stay until about 1pm. Well it DID increase our workload immensely but at the same time it gave me more insight on how the process works.

    We used the Baxter-Fenwall system of blood ID wristbands and stickers.
    You had to hand write the name and hospital number, the date/time and your initials on the wristband. You then drew the blood, tore off the top layer of the nameband and put it on the tube along with a sticker from the band to put on the request slip. To me that was the closest thing to a perfect system there could be. Nothing left the patients side until the blood was labeled and the patient ID'd.

    You then had to have a signed consent of the patient to give the blood. When it came time to request the blood, you had to have the name, number etc and you had to have 2 licensed people at the bedside to check the blood. If the patient did not have on the Fenwall band then the blood went back to the blood bank and the whole process had to be repeated. It relies of course on no shortcuts being taken.

    Anybody else have a different system where they work?
    _____
    Addendum: this is a policy VERY similar to what ours was. I have no connection with this facility and got this using GOOGLE, but it really worked for us at my place.
    http://medweb.uhcolorado.edu/PnPDocs..._C/c059699.htm

    [ June 03, 2001: Message edited by: P_RN ]</STRONG>
    Sorry about previous missent reply.(Learning how this BB works.)
    We use the same banding system at our hospital...I thought it was a national system that everyone used.Just found out few days ago..another hospital transfer..they don't use the blood band system. I am wondering what safety net they have in place.

    A few years ago, our hospital stopped using phlebotomists for inpatient lab draws and trained the nursing staff and CNAs to do the draws. I was apprehensive, but it has seemed to work well from my experience. Though I have to tell you, from the mistakes I see some CNAs make with addressographing the charts with the wrong names..entering the orders on wrong patients...how scarey is it that they are doing the type and cross lab draws? Cold sweat attack!
  8. by   jannecdote
    When I worked as an IV nurse, I had two patients with T&C ordered. I was really busy that day and somehow mislabeled the first draw with the other patient's name. I took the first specimen to lab, and went right back to draw the other specimen when I noticed the arm band did not match my lab labels and instantly realized what I had done. Fortunately for me, I caught the mistake immediately. This was one of those close calls that I have to make myself stop thinking about "What if........."

    One of the techs drew two different T&C on patients in the same room, mislabeled them, and didn't notice the mistake. Fortunately, the doctor noticed the huge difference in the patients H&H's before any blood was given and ordered a redraw.

    Gotta be careful. Where I work now, the night shift has to draw their own labs and if we don't follow policy and procedure to the letter, the blood is thrown away by the lab and every step has to be completed again until the process is completed accordingly.
  9. by   Ruby Vee
    Fifteen years ago in another state, I had just started a job in CTICU where we hang LOTS of products. I was still on orientation when one of the nurses came up to me with a unit of blood in one hand and a blue addressograph plate in the other. "Can you check blood with me?" he asked, making no move toward the patient room.

    "Sure I can," I said, moving toward Mrs. Thomas' room. (Names changed for HIPPA protection and because I can't actually remember them anymore.)

    "Oh, no!" exclaimed the nurse. "We always check it against the blue plate so we don't disturb the patient."

    Even though I was new there, I'd been a nurse long enough to know what a stupid idea THAT was. I told Mike that if he wanted me to check blood with him, we'd check the blood against the patient's arm band -- the one she was wearing. He capitulated, and we checked the blood in the patient's room against her armband.

    My shift was over and I went home. When I came back to work the next day, I heard that there had been a terrible transfusion error. Mrs. Charles recieved a unit of Mrs. Thomas' blood. I had a sick feeling in my gut until after report when I found out what had happened. Mike had worked overtime, and after I left, he and another nurse "checked" the blood against an addressograph plate in the hall. Then he waltzed into the wrong room and hung the blood on the wrong patient!

    What makes this particularly sad is that he did the same exact thing five years later with the same result. And made a slightly different (but equally devastating) mistake with a transfusion five years after that. I figure he's about due for another, but I won't be there to see it!
  10. by   oramar
    Years ago, at the hospital I now work, a patient got the wrong blood because a lab tech drew blood at bedside of both patients in the room and switched them. It just happened again about a month ago. What is the use of nurses taking such care to check if the blood is switched so early in the process. It is very upsetting and my heart goes out to you.
  11. by   traumaRUs
    I can't add anything else except that you have many positive thoughts coming at you. Please take care of yourself.
  12. by   Town & Country
    Oramar your earlier post about the nursing instructor was so true.


    So many things in healthcare just aren't fair. If you dwell on it, it could become disheartening.

    That's one reason I got out of LTC, I just couldn't stand the low staffing....it's so sad. :angryfire
  13. by   UM Review RN
    Our hospital requires that a nurse and the lab tech verify the patient personally prior to the Type & Cross draw, and then an RN with another employee actually verify the blood or blood products, against the Pt's ID bracelet. There is also a verbal check with Pt verbally verifying name and birthdate before each lab draw or transfusion.

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