pt received the wrong blood

Published

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

The OP mentioned being in a hurry as a reason for the error. Did both nurses not go to the patient's bedside and properly ID the patient? Did one sign off and the other went and hung blood on the wrong patient? Purely speculation on my part, but that's the only way I can think that you would know 2 people were immediately at fault.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

this screams SYSTEM breakdown as well as nursing error. I am sure the investigation will include what in the "system" went wrong that allowed such a potentially deadly error to be made in the first place. My heart goes out to all involved, patient and nurses.

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Specializes in Emergency & Trauma/Adult ICU.
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 wonder about this too - an adverse event, nearly immediate determination that the patient received the "wrong blood", immediate termination of 2 employees, notification to the BON -- all on a weekend?

Unusual, to say the least.

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Specializes in ICU/PACU.

When in doubt, blame the nurse.

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Specializes in Critical Care,Recovery, ED.

Was a root cause analysis done? Errors of this magnitude usually are system errors not personnel errors.

Also punishing individuals before this type of analysis is done just leads to under reporting of errors and less safe environment for all.

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Specializes in Infection Control, Med/Surg, LTC.

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.

Yes, saw same thing happen and it was also an inadvertent error of switched tubes by the phlebotomist. No one had to report themselves until the investigation was completed. The nurses were fully exonerated.

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Specializes in HH, Peds, Rehab, Clinical.

Think OP will ever come back and share the rest of the story?

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Specializes in OR, Nursing Professional Development.
Think OP will ever come back and share the rest of the story?

OP hasn't been on the site since 11/15. Really would like to know the rest of the story, but I'm not holding my breath.

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