Stressed over a Sticker

[0402lady]

Earlier this week I was floated to an unfamiliar unit that I have never worked on before. Til around noon my shift had gone surprisingly smoothly until... I had a rather difficult admission arrive to the unit. The phlebotomist came to draw his labs but refused to completely draw his full list of labs because the doctor kept making orders and she would have to return to the patients room. So I was left with several lab orders. I made copies of all the patients labels and grabbed them from the machine. But as I did this I accidentally grabbed a label for a type and screen for a different patient. The blood was drawn and labeled at the bedside including the other patient's type and screen. About an hour later the nurse of the patient who the type and screen label belonged to kept receiving calls about the sample I sent. I realized my error immediately and called blood bank to make sure they were aware that the sample was improperly label and MUST be disregarded. Thankfully no patient was harmed during this incident. I just feel so guilty and shameful that I made such an error. I'm losing sleep over it and feel like I put a damper on my reputation.

[calivianya, BSN, RN]

Our policy includes disciplinary action up to and potentially including termination for mislabeled lab specimens. I would be losing a lot of sleep too, because I would be too worked up to sleep while I was wondering if the phone was going to ring with my manager telling me it wouldn't be necessary for me to come in for my next shift.

What's your job's policy about mislabeled lab specimens? I've only had one job this strict - most places are a little more forgiving. I imagine you'll probably be okay.

[psu_213, BSN, RN]

Our policy includes disciplinary action up to and potentially including termination for mislabeled lab specimens. I would be losing a lot of sleep too, because I would be too worked up to sleep while I was wondering if the phone was going to ring with my manager telling me it wouldn't be necessary for me to come in for my next shift.

Really??? I have heard of disciplinary action for mislabel/unverified type and screens, but never for one mislabeled regular lab--especially when the error was quickly recognized, and the lab was called so they could discard the specimen. Also, mistakes happen. No, they should just be brushed under the carpet, but a little support would be nice…rather that just "the could call you to fire you at any time!"

To the OP, take a deep breath. Yes, it was an error, and it should be reported via incident report. You should make a plan so that you do not make that error again. However, you are human. Every nurse has made mistakes. You recognized the mistake, owned up to it, and made sure the effect of the mistake on the patient was minimized. Realize what you did wrong, but don't beat yourself up over it. Also, the good nurses you work with know that mistakes happen…they have made mistakes. They will not think less of you as a nurse based on this one instance. Hold you head high, and just be more careful with labeling labs in the future!

[icuRNmaggie, BSN, RN]

If you were my coworker I would give you hug. You took responsibility for a major infraction of patient care and that is something that a lot of people don't do anymore.

I have to wonder how the lab picked up on the error - was it because all of the specimens were together in one bag with the same time and signature? I would be thanking the lab person who caught this mistake.

This is also a systems problem. Why do labels for different patients print together and why doesn't your hospital require two signatures on the type and screen.

You will remember this for the rest of career and it will make you a better nurse, so at least something good will come out of all of it.