I forgot to return blood to the bloodbank

  1. So Im a new nurse working on L&D and about 1 month off of my two month orientation. I had a patient who was transferred from the antepartum unit due to placenta previa with active bleeding. When I got report I felt like a chicken with its head cut off, I was trying so hard not to panic. Prior to going to the OR a type and cross was sent and a requisition was sent down to the OR to have 2 units of blood on hold for the patient. This was around 4 am. Shortly after the Dr asked to have the blood be on the unit just in case. I called out to the front desk and communicated this to the charge RN. A nurse came to the OR and said the blood would take 30 minutes (at this point the baby was out) but then no one came back to drop the blood to the OR. Soon after the Dr said she no longer needs the blood. When we came out of the OR I told the pacu nurse (who happened to be charge RN) that the blood wasn't needed. When I returned to work the next day nurse after nurse came up to me telling me I left blood in the OR and the blood wasn't sent back down until 5pm the next day. It was so embarrassing and I felt so bad that the blood had to be wasted. However, during the procedure no one came to the OR to hand me the blood, or say that it was in the room (I assumed it never came up) Now, theres an investigation over my head to figure out what exactly happened and I was told by my manager that I could get written up or worse; fired. I know blood is considered a medication and that the nurse is responsible for following through but I'm so nervous and disappointed that one of my first mistakes was such a big one and I'm afraid I wont be able to come back from this. Is there anyone who've had a situation like this but it worked out for you?
  2. Visit Marie_N profile page

    About Marie_N

    Joined: Nov '18; Posts: 2; Likes: 4

    13 Comments

  3. by   JKL33
    Uh, NO WAY.

    I would absolutely, entirely and 100% refuse to entertain this at.all. My rationale would be never having taken receipt of the blood, period. I would consider myself not involved.

    The very first thing I would've said to the first and all subsequent "informers-of-error" would be, "I did no such thing. No one delivered any blood to me." Period.

    Wow, this makes me angry just hearing about it.

    There was a mistake, alright, an error in process. Rather than being embarrassed and feeling bad (which, sorry, I wouldn't have since this has utterly nothing to do with you), you need to think straight and not be self-deprecating in situations like this. Do NOT accept responsibility for problems unless you actually bear the responsibility.

    Can't give advice about the tone/exact approach you should use at this point in the game, but I do think you need to start talking about how you did not take receipt of the blood and no one informed you of its delivery, thus you had no idea it was in the OR.

    ETA: Your reaction to things like this basically set the tone for your employment relationship in this place. If you don't have any expectations about how you will be treated, then every day will just be a crapshoot with regard to random harassment vs. respectful treatment.
  4. by   JKL33
    Okay (now that I've calmed down a tad, lol), one point of culpability on your part: When the doctor said blood was no longer needed, you should have immediately communicated that to blood bank (or whatever your process is) - which is an action that is prudent for other reasons, but it in this case it might have helped prevent this type of thing from happening. Telling the PACU nurse that the blood wasn't needed isn't the same thing - since that statement could mean several different things (blood was never delivered because it wasn't needed, blood wasn't needed and has already been sent back, etc.).
  5. by   Kallie3006
    Was there only an order to have the type and screen for on call to OR, or was there an actual transfusion order? I dont know your facilities policies but at mine, we have 30 min to initiate the transfusion from when the blood was verified and picked up from the blood bank. In my opinion, the person who signed for the blood from the blood bank dropped the ball. Who did they give it too? There are so many variables and steps to follow to ensure safe administration of the blood should not have just been causally set somewhere, and when said person received it they are assuming responsibility for the unit. That responsibility is to get the unit to the person in care of the patient or an acceptable and appropriate person, ie the charge nurse. This is no way should be placed on you for blame as you never received and therefore accepted responsiblity for the unit dispensed for your patient.

    I agree that the blood bank should of been informed of the unit not being needed at that time, but who's to say the unit wasn't already in route or in the OR when the doc determined it was no longer necessary. And if it was picked up after deemed unnecessary, was it brought to the OR with the patient still in the OR or PACU? Or when the patient was recovered and brought to the floor? Why did said pick up person not find where the patient was to bring the blood to their location, ie... if the patient was in the OR and it was brought to the unit or vice versa? What the PACU charge the same charge you told about the request to have the blood brought to the unit? If so, this person would have received report when the patient arrived in the PACU, and your informing it was no longer needed, to me in this scenario, makes sense and should not have warranted further explanation on your part.

    Why was the blood not returned until 5pm the following day? Did the room not get cleaned until then? Did the person that found the blood hold on to it for some reason before returning it? Or was it not found until that time, again demonstrating the lack of communication and responsibility of the person that picked it up to begin with?

    I would not stand for this getting pinned on you, the only thing that you may hold some responsibility for, is possible communicating to the blood bank when the blood was not warranted any longer.

    You are a new nurse with 1 month solo after a 2 month orientation ( 2 months really?? That seems way to short, especially for such a specialized area, but that's a different issue in itself) you communicated with your charge, who also did not follow up in this situation.

    IMO, you are not to blame in this, and if it were me I would be damned if it would be made out to be my fault.

    Sounds like someone is throwing darts blind and you took the hit. I hope the investigation proves your role in this and clears you of any fault in this situation.

    Keep us updated if you dont mind, I'm curious how this is going to end. Good luck
  6. by   jennylee321
    This would be a stupid thing to be written up or fired over. Occasionally blood gets wasted it's an occupational hazard and you were busy taking cars of your patient. If it was never in your hands then it must of made it to someone else's, and clearly they never handed it over properly to anyone else. We're you meant to go on a scavenger hunt for blood that you weren't sure had come up? Or take care of your newly delivered mother ? Just sounds like administrative crap to me
  7. by   canoehead
    Who was responsible for clearing the OR after the surgery? Probably the circulating nurse. The blood was still in the OR, so it should have been noted and dealt with then. Or they should have sent it out with the mom, passing it on as part of report. But I also don't see it as your responsibility, unless you signed for it.
  8. by   klone
    Agree, not your responsibility!! Did your manager REALLY say you might get written up or fired for this?? I'm pissed on your behalf.

    This was clearly a process/communication issue. Whoever physically took the blood from the blood bank and brought it to the OR dropped the ball by not using closed loop communication to physically give you the blood.

    And like others, I'm wondering why the OR was not turned over until the next day.

    OP, do NOT take responsibility for this!
  9. by   Been there,done that
    Whoever signed for the blood is responsible for it not being returned.

    Think you have a bigger problem, that would be your manager.
  10. by   City-Girl
    Sounds like a systems problem that everyone can learn from (many errors are). The ordering MD should have entered an order to d/c the blood. You did tell your charge nurse that the blood was no longer needed so maybe you thought that was the last time you would have to think about it. In an ideal world, you would have had the time to notify the blood bank that you did not need the blood or have watched for it's arrival and send it back. Where I work, once the order for a blood product is entered by the physician, the nurse is required to send a requisition form to the blood bank notifying them that she (he) is ready to receive. The blood is send through the hospital's pneumatic tube system and whenever something is delivered a rings a bell until the delivery is taken out. There have been a few times that I can remember in the past 20 years where blood has arrived and unfortunately everyone on the unit was too busy to notice. Unfortunately sometimes things like this happen. If you haven't already, fill out a variance (incident) report. Although you may usually think of these kinds of reports for errors or patient harm (medication error, patient injury), this is not to place blame, but to provide insight into how these sorts of things can happen. It will also show your manager that you understand your part in why this occurred.
  11. by   Accolay
    You didn't leave the blood in the OR because you never received it. That's what you need to make sure is heard. You had no idea it had even arrived and attempted to communicate that you didn't need what you hadn't received to the charge in the PACU.

    Whoever signed for the blood was responsible for it. If you didn't physically have the blood given to you, and nobody told you it was there, then how would you even know where it was?

    Ever heard that old adage "if you want something done right, you have to do it yourself" ? I understand it's hard to worry about one thing in a hectic situation. Next time afterwards for sure find out if the blood was delivered at all or who signed for it and where it is.
    Last edit by Accolay on Nov 17
  12. by   TriciaJ
    This was clearly a systems error and they're now trying to play "Let's pin it on the new grad". The investigation should be trying to discover the chain of custody for that unit of blood and where the communication errors occurred. Your manager's behaviour toward you reminded me of something that happened to me many years ago on a med-surg unit:

    I was in charge one evening and received an ER admit. In report I was told this person had a condition (can't remember the name) that caused her to have very low potassium at baseline and I shouldn't be concerned. Also the resident was coming right up to work her up. The patient was asymptomatic, no distress. I put in a couple of calls to the resident to get an ETA and was told "I'm coming up as soon as I can." I never did see the resident and reported the whole situation to the oncoming charge nurse.

    The next day I was approached by my regular charge nurse because the powers-that-be were demanding to know why I accepted the admit and not had the patient admitted to the ICU with her potassium level. I reminded her: 1. I was led to believe the resident was arriving imminently 2. The patient was asymptomatic 3. I was told not to be concerned about the potassium due to her baseline 4. I do not have the authority to refuse an admit and would do so only in more glaring circumstances than that one 4. I do not have authority to transfer someone to ICU without MD approval and the MD was arriving imminently. I finished with "I am not owning this one."

    That was the last I heard of it. Someone screwed up and was playing "blame the nurse". I completely agree with JKL and others that you need to be clear that this isn't your error. If they want to adjust policy so that in the future there will be a specific procedure for you to follow, great. Meanwhile, this isn't yours.
  13. by   boywithacoin
    OP, please keep us posted.
  14. by   dennis8
    Quote from Marie_N
    So Im a new nurse working on L&D and about 1 month off of my two month orientation. I had a patient who was transferred from the antepartum unit due to placenta previa with active bleeding. When I got report I felt like a chicken with its head cut off, I was trying so hard not to panic. Prior to going to the OR a type and cross was sent and a requisition was sent down to the OR to have 2 units of blood on hold for the patient. This was around 4 am. Shortly after the Dr asked to have the blood be on the unit just in case. I called out to the front desk and communicated this to the charge RN. A nurse came to the OR and said the blood would take 30 minutes (at this point the baby was out) but then no one came back to drop the blood to the OR. Soon after the Dr said she no longer needs the blood. When we came out of the OR I told the pacu nurse (who happened to be charge RN) that the blood wasn't needed. When I returned to work the next day nurse after nurse came up to me telling me I left blood in the OR and the blood wasn't sent back down until 5pm the next day. It was so embarrassing and I felt so bad that the blood had to be wasted. However, during the procedure no one came to the OR to hand me the blood, or say that it was in the room (I assumed it never came up) Now, theres an investigation over my head to figure out what exactly happened and I was told by my manager that I could get written up or worse; fired. I know blood is considered a medication and that the nurse is responsible for following through but I'm so nervous and disappointed that one of my first mistakes was such a big one and I'm afraid I wont be able to come back from this. Is there anyone who've had a situation like this but it worked out for you?
    Hello OP. I had a similar experience recently. I work in Med-Surg and I made a stupid mistake. Had a patient who was going for procedure in the AM and an order to transfuse platelets at 0800. I work nights so typically an order at 0800 would fall on the day shift nurse to do the transfusion but I always try to help out when I can. At around 6:30 I ask my buddy coworker to fetch platelets. He comes back around 6:45 and we verify the platelets and patient. I stupidly spike the bag of platelets and prime the tubing before checking vitals. When I checked the temperature it's 100.2. Well... I didn't want to begin the transfusion while the patient was having a fever. In our facility we need to hang the platelets within 20 minutes of receiving. I don't know if it was because of the sleepiness or all my other patients suddenly needing things, but I just documented that the patient had a fever and I will endorse the transfusion to the next shift. Told the AM nurse in report that the platelets is still up there but patient is running a fever. I was hoping that the fever would go down and she would be able to hang it. Anywho, I didn't hear about anything until the following week when I was off work and I got a call from a coworker to call our unit. I was told by the day shift charge nurse that the lab manager was getting fussy about the spiked bag of clotted platelets that was returned to lab. To make matters worse, the patient was a former worker at the lab so the bosses in the lab were even more concerned about the issue. Long story short, the day shift charge spoke to the lab director and vouched for me. I spoke with my unit supervisor who said that it was a stupid mistake but she knows that I won't do it again. I signed a paper that states that the unit supervisor reviewed with me regarding the policies and procedures of blood product administration. From level 1-5 it was a level 1 or verbal discipline. She stated that it doesn't stay on my record. If it happens again, she can't guarantee that though (it definitely won't!). But based on what you said, it doesn't seem like it's mainly your fault. Until the investigation is over, I wish you the best of luck!
    Last edit by dennis8 on Nov 18 : Reason: error

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