pt received the wrong blood

Anonymous865 · Nov 16, 2014

Here's a discussion of what may happen if incompatible blood is given in a transfusion.

Blood transfusions and the immune system - Blood Groups and Red Cell Antigens - NCBI Bookshelf

This is quite a sad situation for everyone involved (patient and nurses).

imintrouble, BSN, RN · Nov 16, 2014

Nurses make mistakes because we're human.

Situations like this make my heart hurt for the patient AND the nurses.

It doesn't make me "sick to my stomach". I won't condemn a nurse who makes such a mistake. They'll be paying for that mistake for the rest of their lives.

xoemmylouox, ASN, RN · Nov 16, 2014

How sad and scary. I don't see how they both made the same mistake. Has an investigation been done to find the cause? Were they rushing, short staffed, was the label confusing, or perhaps they were both inexperienced? Accidents do happen. Those nurses will feel terrible for the rest of their lives. Hopefully the patient survives.

RainMom · Nov 16, 2014

What about the first check off with lab? Did that employee also lose their job? I wonder about the labeling as well; seems hard to wrap my head around all these people missing the incompatibility.

Loo17 · Nov 16, 2014

Have they determined the cause of the error? When something happens (especially that causes severe patient harm) facilities will often place the parties involved on suspension pending the investigation. Where I work if the person is found to be not at fault they get paid for the days they were suspended. It is possible that the blood transfusion tag was not properly filled out by the two nurses (all the boxes weren't checked, the vitals weren't properly documented, etc) therefore they could be suspended for not following protocol not necessarily for giving the wrong blood.

This is a very sad situation but unless you know 100% that the two nurses gave the wrong blood there could be other causes to consider for the transfusion reaction. The patient may have had an antibody reaction for example. Or maybe the patient had a reaction and happened to be given a compatible blood type versus their actual blood type and the rumor mill just got the story wrong. It would be a violation of the nurses privacy for the facility to be telling everyone that the nurses gave the wrong blood, were fired and that they had to report themselves to the board. People like to talk and make conclusions. I would be sure you know the facts. If this just happened today (the day you posted) it is highly unlikely anyone knows what really happened yet.

Jolie, BSN · Nov 16, 2014

I'm not looking to excuse anyone who may have failed to follow basic safety guidelines, or nail anyone who played no role in this terrible mistake. But if 30 years of nursing have taught me nothing else, they have taught me that catastrophic errors are rarely, if ever, singly the fault of the poor soul who happens to be the last link in the chain of care delivery.

We know very little, but I highly doubt that 2 credentialed nurses could possible read a blood bag together and fail to notice that the name, patient ID, room #, blood type and Rh, ordering physician, etc. were incorrect. This makes me wonder if multiple units were sent to the same nursing station at the same time, checked, then inadvertently switched. Or whether there may have been a labeling error. Or a mix-up in the pre-transfusion labwork that improperly identified the patient's blood type. Or two patients with the same name, or, or or any of a thousand possible scenarios.

My heartfelt prayers to the patient, family and staff.

A sober reminder of the possible complications of treatments we may take too much for granted.

Mulan · Nov 16, 2014

we had to send a pt to the ICU today because the nurses who gave and witnessed the blood for him didn't check correctly. made me sick to my stomach ,,, never in my day have i seen a pt's safety above being in a hurry ... they had to turn themselves into the board and lost their jobs .. they are waiting to hear from the board if they will be investigated or not .. the pt is still in ICU ... will he ever be able to receive a blood transfusion without antibody problems ?what are the pt's long term effects from receiving a unit of the wrong blood? how do they reverse the wrong blood in a pt's system? dialysis? thank you in advance

Was the reaction noted immediately?

What was the reaction?

Did the nurse involved pick it up?

Did the next shift pick it up?

More details please.

Saw this happen many years ago, on a post-op C section patient.

I was not involved.

The nurse hung the blood and shortly thereafter the foley drainage was bloody.

Everything checked out correctly on the nurses part.

It turns out that a lab tech drew blood in L&D and there were two patients with very similar names and the lab tech mislabeled the blood.

LadyFree28, BSN, LPN, RN · Nov 16, 2014

Was the reaction noted immediately?
What was the reaction?
Did the nurse involved pick it up?
Did the next shift pick it up?
More details please.

This.

There may be more to the story that meets the eye. :yes:

BuckyBadgerRN, ASN, RN · Nov 16, 2014

we had to send a pt to the ICU today because the nurses who gave and witnessed the blood for him didn't check correctly. made me sick to my stomach ,,, never in my day have i seen a pt's safety above being in a hurry ... they had to turn themselves into the board and lost their jobs .. they are waiting to hear from the board if they will be investigated or not .. the pt is still in ICU ... will he ever be able to receive a blood transfusion without antibody problems ?what are the pt's long term effects from receiving a unit of the wrong blood? how do they reverse the wrong blood in a pt's system? dialysis? thank you in advance

Wow, that was a pretty fast investigation and firing---all of this happened in one day. On a weekend? I think there HAS to be more to the story, blood products administrations passes up/down a VERY long chain of personnel before it is actually hung by an RN. I hope OP comes back with more details because I just can't believe that TWO nurses at the end of the process effed up and were fired practically on the spot

LadyFree28, BSN, LPN, RN · Nov 16, 2014

Wow, that was a pretty fast investigation and firing---all of this happened in one day. On a weekend? I think there HAS to be more to the story, blood products administrations passes up/down a VERY long chain of personnel before it is actually hung by an RN. I hope OP comes back with more details because I just can't believe that TWO nurses at the end of the process effed up and were fired practically on the spot

I agree.

Did they check who the pt was?

Did they check the Labs against the blood?

Did they check with two people as well as before the blood was hung?

Were they monitoring vital signs and the pt during the first 15 mins?

So many questions unanswered...

ktwlpn, LPN · Nov 16, 2014

That's a scary thing-lay people seem to take transfusions pretty lightly. I'm in LTC and we have number of folks with various types of anemia who have refused further invasive testing to determine the cause but they, their family and the doc wants to continue monitoring them and send them out periodically for a "top off",as they say. Several are demented and this takes a toll.They just don't get it.