Gave pt the WRONG blood! - page 3

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   V. Nightingale
    Oh, wow, codebluechic, that's an awful thing to have happen. My heart goes out to you.

    Plesase don't take this question the wrong way, but how did the patient get 8 units before anyone noticed a reaction?
  2. by   June55Baby
    I know there are alot of complaints from hospital staff about JCAHO and CMS and all their requirements, but this is a prime example of why the National Patient Safety Goals were developed.

    The first NPSG is Patient Identification and requires 2 identifiers (never the patients room #) before medication or blood is administered or lab work is drawn.

    Nurses are SO BUSY and there is SO MUCH paperwork, but we've go to do things the right way the first time and not following policies can come back and bite you.
  3. by   dphrn
    Quote from codebluechic
    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 didn't help things. Although they say her reaction was mild I still feel awful.She is still alive but nobody is sure if she will make it.(cardiogenic shock,multi-organ failure)I don't know how I can trust the lab again. Thanks guys...just needed to get this off my chest.
    Were the actual units labeled wrong? Could you elaborate on what their error was. I am curious.
  4. by   miss.bandaid
    Not your error at all! Please don't be hard on yourself, there was really nothing you could do.

    My "blood product" story happened when I was a new grad. 3 months into my career I show up to the unit for a night shift to find I was in charge. Our unit was understaffed and I only had 2 other new grads to work with! We started our shift with some pretty sick kids and a new admit that needed platelets infused promptly upon arrival to the unit(patient was accepted by day staff and delivered to unit right at shift change). My nurse manager gave me the name of a more senior nurse on another unit to call with any concerns, and said she had no other choice then to staff this way. I can't remember the specific orders, but I remember thinking the time to infuse the platelets was too short. I phoned the resource nurse and she was no help. I set the pump for some outrageous rate( I think it was 2 units, 30 or 60mins each), but the pump would ring every five minutes. I called the oncology unit where they infuse blood products daily. The nurse told me that the rate was fine, and that the pumps sometimes do that.... Next shift I come on and hear the rumors of what a horrible mistake I made(patient was fine to my knowledge, but the rate of infusion was the concern). I felt totally unsupported that night, made due with my resources, yet still screwed up. I started to write an incident report re:feeling unsafe in the workplace, but never handed it in. I can't remember why I didn't finish the report, I think I was scared of my manager! My manager had made other mistakes with staffing that affected care too. I wasn't on this shift, but I heard she left the unit early, leaving only 2 nurses on the floor. One patient turned for the worst and ended up dying, the docs were calling into the hall "we need a nurse in here!", but the 2 nurses were in rooms with other patients(heresay, but plausible).
    Last edit by miss.bandaid on Sep 29, '04
  5. by   Horseshoe
    Quote from Lab Scientist
    Thanks for this because now I know you're full of it. You can't give someone EIGHT UNITS of B blood when they're type O unless they have absolutely no immune system whatsoever without them having an immediate anaphylactic reaction and almost immediate death. Usually within giving about 15 to 30 cc of incompatible blood of this type from the very first unit is when a mistake of this magnitude is caught.

    I have heard stories of a type O patient (cancer, elderly) being given four units of AB blood and this person lived four days after. But this is an elderly cancer patient who was virtually unable to mount an immediate immune response. It took days (a delayed reaction) for death to occur.
    How did you manage to come up with a thread that is 11 years old?! I can't even find a thread I was interested in from a week ago.
  6. by   msjellybean
    Quote from Horseshoe
    How did you manage to come up with a thread that is 11 years old?! I can't even find a thread I was interested in from a week ago.
    Similar thoughts.
  7. by   nursel56
    We've had a whole raft of lab-related threads unearthed lately.
  8. by   brillohead
  9. by   klone
    OH, for G-d's sake. An 11-year-old thread?? Why?

    Lab Scientist must have some phlebotomy muscles he needs to flex today.
    Last edit by klone on May 6, '12
  10. by   NurseCard
    OH lord, this happened 11 years ago!!!!

    How is this nurse doing today? =)
  11. by   traumaRUs
    I think we can safely say that in the ensuing 11 years a resolution has been found. Thanks everyone.

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