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.

+++++

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..."

[Do-over, ASN, RN]

I am learning that there is ALWAYS time to double check...

All of us should be especially cautious in the atypical or urgent/emergent situations... that's when the systems checks are most likely to fail.

[amber_energy_RN]

Yep, double-checking is pretty basic stuff on the unit. Actually our system forces a triple-check with a second witness in order to transfuse blood even in emergent situations.

[dudette10, MSN, RN]

To the OP, thank you for sharing your heart-wrenching story in the other thread, and also thank you for continuing to share your experiences from which we can all learn.

[waterbabies]

No amount of new technology is a substitute for good technique. Thanks for sharing.

[smf0903]

Funny I just posted an article on our school nurses' facebook page about a patient who died from an error in transfusion. Pt was O and received B blood brought up for another patient. No vitals were taken during the transfusion (according to article). According to the article the patient received blood, a "reassessment" 4 hours later ended in a code blue, and pt's time of death was called a little over an hour later.

This is one thing that has been drilled and drilled and drilled into us at our school. The floor I did clinicals on last semester had quite a few transfusions while we were there. The nurses do vitals more often and longer than is required, and I can't tell you how many times we were told by the RNs "You can't be too careful with blood products...ever".

Thank you for sharing this!

[NotReady4PrimeTime, RN]

In my province, blood products are a two-person check; RNs, physicians and perfusionists are the only personnel allowed to do these checks. When a patient is typed and screened, two persons are involved, one to identify the patient and the other to collect the blood for matching. A unique numbered band is placed somewhere on the patient, usually on the same limb as the patient's ID band. This is their blood bank identifier. Each unit comes with a gigantic two-part tag labeled with the patient's name, blood group, Universal Lifetime Identifier, the patient's blood bank band number, the type of product, the blood group of the donor, the expiry date and time of the product and a 17 character identification number. One person reads the patient's name, ULI and blood bank band number from the patient, spelling the name out while the other compares what is on the label. Then when the right patient has been identified, the blood product is identified by one person reading from the bag itself the type of product, the 17 character identifier and expiry date while the other compares. Only then can the product be used. Occasionally we run into a product that doesn't match and the blood bank is only too happy to have us return it. Sounds pretty foolproof, don't you think? It's not. Several years ago we had a sentinel event where a patient received the wrong blood when an ECMO specialist (who isn't a nurse) pulled the wrong bag from the blood fridge, didn't check it with anyone, drew up a syringe full and then started pushing it into the ECMO circuit. It was stopped within seconds when the bedside RN noticed the syringe in the person's hand and the patient was only minimally exposed. There were long-term repercussions. Our blood fridge was taken away and units of blood are now stored in coolers at the bedside to this day, five years later. It was a huge increase in workload for our service attendants who must return the coolers to the blood bank every 8 hours to have the ice packs changed. We have purchased one of those blood dispensers similar to Pyxis but it hasn't been put into use yet.

The OP truly did save that patient's life and deserves a pat on the back if nothing else!

[stronginchrist]

I really loved the " we as nurses are the last door the reaper have to go through to get to the patient" I think that was a very strong statement I even posted it on my facebook wall. Love love love it

[Mas Catoer]

That is what I always want to have in our nursing division. Do all critical step with caution. Always assume things have its potentials for error. Good job, Nurse..!

[didi768]

"we as nurses are the final door through which the reaper has to pass to get to the patient... "

Whoa... that was profound.....great card/t-shirt/bumper sticker idea