Need advise

[nursesausha]

Something happened in our women's clinic and I need advice. We had a patient come for pap smear and I always label the specimen at the bedside, however, the lab requisition (paper order) is placed in the pocket of the specimen later when the provider prints it off. Well somehow another patient's requisition was put in the bag so it did not match the specimen. Within three days I called the two patient's who were supposedly swapped and made them appts to have specimens recollected as the lab requested. One patient has already had her pap and it was fine the other patient was to come in this next month to have her pap done again. Well the patient (who has not had a repeat pap) had some urinary problems and saw a urologist who ordered pelvic CT. The CT came back with possible endocervical endometrial malignancy. I am glad that the patient had a CT to discover this. It has only been a month, I am glad that they found the possible cancer now. Should I feel at risk for medical negligence, I did call the patient and reschedule her to do another pap. I have never had anything like that happen before and it really has me down.

[NotReady4PrimeTime, RN]

That process seems backwards to me. The requisition should be printed FIRST and then the specimen collected. That would reduce the risk of mixups significantly. Perhaps there should also be a two-person check when the specimen and requisition are placed in the bag as well, which is what we do when we collect crossmatches and types-and-screens. Having said that, I fail to see how it could possibly be your fault that this patient hasn't yet attended the clinic for a second swab. You notified her as soon as the mixup was caught and followed through according to the usual practice in your clinic. The person who mixed up the requisitions is at fault. And if the possible malignancy was picked up by CT then it was already well underway when the first test was done. Will it make a difference to the patient's treatment and outcome? Maybe.

When you go back to work pull your office policies on collecting, labelling and dispatching specimens. It's possible that the current practice isn't following policy. At any rate, the process needs an overhaul.

[SummerGarden, BSN, MSN, RN]

should i feel at risk for medical negligence, i did call the patient and reschedule her to do another pap. i have never had anything like that happen before and it really has me down.

no, this should be written up by you as an incident report that should be non-punitive. honestly, the process itself, as the above poster pointed out, is at fault in some way. an incident report may help to change the process for the better, which is why incident reports exist in the first place; rather then a mechanism for abusing nurses. therefore, write it up and offer suggestions to remedy this situation in the future.