behind the scenes issue

Nurses Safety

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Hi all,

I am not a nurse but I work closely with nurses at a large hospital in a blood bank. I am a medical technologist. I had an issue a few weeks ago and I am looking for advice. We have a relativiely new tech (shes been here about 6 months). She is a good worker, friendly person and does an overall good job. She does not make many errors. She is fairly new to issueing blood products out to patients and sometimes we get completely slammed. She was filling an order for a person who was AB, plasma, who can only get AB plasma. She was in a rush and accidently grabbed type B plasma and tried issueing it to the patient. She was working on 3 different orders at once. Another patient she had was type B. She was trying to issue the type B plasma to the AB person. The computer flagged her and her and another technologist couldnt figure out why the computer was flagging them and they called me over and thats when I realized she was trying to give the wrong type. She flipped out when I pointed out the blood type in the header to her and realized why the computer was falgging her. Needles to say she felt horrible for doing what she did. It was caught very early and it would have not left the lab either way. I could have written her up for that, but after talking with her i realized we have all made mistakes. Its just a reminder how careful you have to be. That is one of the biggest mistakes you can make in blood bank aka give the wrong blood type. I spoke with her about it and she told me she thought she was working on the patient that was type B. I told her she needed to be really careful next time and only do one order at a time. I was just wondering what any one of you would have done? If I did write her up, it could cost her the job. But as of now, I have decided to let it slide. I dont think she will ever do that again and thank god for computer flagging, I have seen this error before.

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Specializes in Trauma Surgical ICU.

I wouldn't write the tech up... I think you were right in the way you handled it. Does your company have Risk Management? I might write the incident up so the issue can be tracked in order to safe guard the system further. Our "write ups" are used to help make the system better and near misses are not used for discipline actions (no names). If your system is similar, I might write it up.

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we do have risk management. this issue has happened in the past. I do not believe writing it up will solve anything honestly, it was just an oops, now if she had decided to not ask anyone and go ahead and override the error and than discover it i would have written it up, but she took the proper precaution by asking her fellow techs.

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Specializes in Critical Care.

If writing up something like this gets someone fired then I wouldn't write it up, that's been known to be bad practice for some time now. Firing people for making honest mistakes doesn't reduce the incidence of mistakes, it just teaches people to cover them up, which then only prevents the systemic issues from being fixed (like having backup for when a blood banker gets overwhelmed with workload).

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Specializes in Critical Care, Education.

Sorry but I have to weigh in on the other side here.

It's important to document and track "near misses" in order to develop and maintain a high-reliability system. These are used to shed light on underlying issues that may be impacting safety/quality. Of course, you also need to have a non-punitive philosophy that analyzes these issues based on a "Just Culture" type of framework that does not dole out punishment for human error.

Just playing devil's advocate. What would happen if this same individual does not learn from this mistake, and continues to exhibit sloppy behavior, cutting corners whenever the workload increases? How will you be able to take appropriate action if there is no actual (documentation) evidence of this pattern of behavior? I have been involved in too many cases where this has happened "after the fact" of a serious clinical error... when it becomes obvious that someone has had problems for quite some time, but no one realized.

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I agree that near misses are important, but that does depend heavily on the facility following up on it and using the opportunity to improve. Some places do, some don't.

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Specializes in Critical Care.
Sorry but I have to weigh in on the other side here.

It's important to document and track "near misses" in order to develop and maintain a high-reliability system. These are used to shed light on underlying issues that may be impacting safety/quality. Of course, you also need to have a non-punitive philosophy that analyzes these issues based on a "Just Culture" type of framework that does not dole out punishment for human error.

Just playing devil's advocate. What would happen if this same individual does not learn from this mistake, and continues to exhibit sloppy behavior, cutting corners whenever the workload increases? How will you be able to take appropriate action if there is no actual (documentation) evidence of this pattern of behavior? I have been involved in too many cases where this has happened "after the fact" of a serious clinical error... when it becomes obvious that someone has had problems for quite some time, but no one realized.

I think you've confused what's been argued. We all agree that it's better to document for the sake of improving the system and preventing future problems. If a write-up such as this results in termination, it doesn't help improve the system, it just teaches everyone not to document this sort of thing, which will will never prevent the circumstances that caused the problem.

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Specializes in I/DD.

It is important to document near misses so that measures can be taken to prevent them from being repeated next time someone makes the same honest mistake. In this case, the measure that was already in place (computer flagging) worked. I think this should be documented and looked upon as a case when the system for prevention of serious medical errors worked, and hopefully a very valuable learning experience for the people involved.

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Specializes in Med/Surg, Academics.

The system worked. What is there to write up?

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Specializes in Trauma Surgical ICU.
The system worked. What is there to write up?

Re-read the OP's response, the tech could have overridden the system.. That is an issue, not with the tech but with the system.. That is our point. No the tech should not be written up but the "issue" should to further safeguard the system and pts..

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Specializes in Med Surg, Specialty.

From what it sounds like, this is a good, hard working person, who made a human mistake, like we all have. Do an incident report - definitely, but not write up/firing.

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I wanted to thank everyone for their comments and also provide an update. Thus far, the individual has not made any more serious errors. Lately though, I have found myself very annoyed with her. She seems to zone out a lot. She also asks many questions, I mean she will ask the same question three times in a row. I told her she should go back over some of the SOP's so she can better understand what she is doing independently. She also complained to our supervisor I was being too hard on her. She informed them I was making her very nervous. As I heard, I guess I almost made her quit because one night she asked me the same question 4 times about giving O pos blood to a BMT patient who was changing types after a bone marrow and the patient information was not clear. Well I lost it and told her to find another job. I did feel bad about that so I talked with her afterwards and she said it was ok, she was just trying to make the right decision. I used to like the individual, but now, I find myself annoyed with her ever since she went to supervision about me. I guess I am a bit hard on her, but now, when she asks me questions, I give her real short answers and she has been asking other people. People seem to like her, I guess its just a personal thing for me.

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