Gave pt the WRONG blood!

  1. 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.
    •  
  2. 36 Comments

  3. by   Future LPN Sheryl
    Oh my God, what a horrible mistake on the labs part. I don't blame you for how you feel.
  4. by   P_RN
    OMG that is terrible. Was it a type specific problem? Rh problem? I know a girl who gave one patient another's predonated autologous blood! Fortunately both ladies had the same type. They had similar names and each was in bed 1 of a semiprivate room. I know you had nothing to do with the error, it being the labs but I'm sure you still feel bad about it.
  5. by   codebluechic
    It was about as bad as you can get. The pt was O and she was given B.
  6. by   fiestynurse
    All of us feel awful when we are involved in mistakes in patient care, but mistakes are almost always system errors and not the result of one person's act. There is usually a kaleidoscope of events that led up to the error. Nurses often feel "set up" when mistakes happen. Luckily, the patient was not greatly harmed. You sound like a very competent nurse who cares about her patients and that is what makes this hard. Hopefully your organization is looking into the incident and making the appropriate changes, so this doesn't happen again. Try not to talk about the incident with too many people, just your nurse manager and risk management, in case this turns into a legal issue. Now, GO OUT AND DO SOMETHING NICE FOR YOURSELF!!
  7. by   mustangsheba
    Code: My heart goes out to you. I would have hurled all the way home. Right now, I can't think of a thing you could have done at the time that would have avoided this. That is the really scary part isn't it. What can we learn from this? That we can't trust the lab? Oi vey! I gave one unit last night. I wonder if it was the right type!
  8. by   codebluechic
    Thank you for the supportive replies! It really helps.
  9. by   CEN35
    Not that it matters? But was the blood mislabeled? sheeeshe......I dont know what to say? I would feel sick......aweful I hope you do feel better......and more important I hope the patient comes through ok. Like somebody else said, DO NOT discuss it with anybody else.

    I hope ya feel better!
  10. by   Jay-Jay
    Codeblue, if it makes you feel any better, I got nailed TWICE for mistakes giving blood, and both times, someone else was at fault. Fortunatly, no one was hurt...

    The first time was my first time giving blood since nursing school. An experienced RN went through all the checks with me, and we co-signed everything, then she went in to the patient's room and helped me hang the blood. It wasn't till it came time to flush it through that I looked at what was hanging along with the blood, and saw it WASN'T normal saline, but some other IV fluid! I still got flak for not noticing sooner. The fortunate thing was, the bag was not running, so the patient only got a small amount of this solution along with the blood (at the very start of the infusion, when I flushed the line.)

    The second time: same unit. Told to give 2 units PRC's. Checked MD's order: 2 units PRC's over 2-3 hrs. with 40 of Lasix in between. OOOKay! 45 minutes per unit, right? Gave the first unit, hung the Lasix, then came back to the nursing stn., and asked a nurse how to get second unit up to the floor. Her eyes went wide with shock: "You finished giving that blood ALREADY?? That's way too fast!"
    I showed her the doc's order, and she said it should have read "over 2-3 hours for EACH unit."

    The upshot of this all was, because I was an agency nurse, I was not allowed to work at that hospital again, AND my supervisor suspended me from my duties as an RN. After going through h*** for several weeks, I managed to get another job, which I love!

    I still shudder when I look back at it, though. I thought my nursing career was over!

    I'll say a little prayer for you and that patient. I can appreciate just how awful you must feel.
  11. by   imaRN
    "Amen" to feisty nurse's comments.And do you think If you were a doc, you would be saying a word?(not a judgement), Just something to think about....

    [ June 03, 2001: Message edited by: imaRN ]
  12. by   oramar
    Very early in my career I saw a person have a sever reaction to blood. When the incident was investigated it was found that a tech had drawn a type and cross on two patients in the same room at the same time and then mislabled. I was a PN and could not hang blood at the time but later on when I got to be an RN I worried all the time about the same thing happening to me. Darn if I know how to avoid a mistake like that. Most the time when a person is typed and crossed it is not even done on my unit or my shift.
  13. by   codebluechic
    Originally posted by imaRN:
    <STRONG>"Amen" to feisly nurse's comments.And do you think If you were a doc, you would be saying a word?(not a judgement), Just something to think about....</STRONG>
    The doctor DID inform the family about it...I was impressed with him for not covering it up.
  14. by   fiestynurse
    Ethically, of course the right thing to do is to tell the patient or family in this situation. But, don't give the doctor too much credit here codebluechic, his butt wasn't on the line. He didn't have anything to do with the mistake, did he? What imaRN was trying to say, was if the doctor would have been the one to hang the wrong blood, the judgement would have been different. Doctors handle their mistakes differently than nurses.

close