I’ve
signed up to the mailing list of “The Mislabelled Specimen”. A lot of
their postings are somewhat flippant, but so am I.
Here’s
a post about a case of massively high potassium because a nurse took the
blood into the wrong sample bottle and tipped it over. Things like this happen
from time to time. However what boils my piss (I said I was flippant!)
is the attitude from the one making the mistake who was quoted as saying: “I
hate drawing blood for this reason. You guys are always picky with your tube
colors. I drew it in a tube with a purple cap. My supervisor told me that I
drew the wrong tube. So I transferred it to a green tube. I can’t see how it
would affect her potassium level!”
Fortunately
this error was spotted before any harm was done.
There was
a post which was not entirely dissimilar on the Facebook “Blood
Bank Professionals Group” this morning in which a clinician ws in a
hurry to get blood for a patient with a haemoglobinopathy, and rather than
getting phenotypically matched blood he wanted O Neg as everyone knows that’s a
universal donor (!)
Slightly
(much) more serious was a case I heard about in a hospital fifty or so
miles from where I lived at the time in which a child had been born with HDN
due to anti-K. Apparently the lab (not mine!) had been constantly
telling the ante-natal clinic about the matter, but the consultant obstetrician
had declared that because he had never heard of anti-K it couldn’t be
important.
Cases
like this occur from time to time. But what do we do about them? Ideally one of
two things. We should use them as a learning opportunity. And if nothing is learned
then they should be reported to the appropriate regulator as a clear and
present danger to patient safety.
But we
don’t do we? We roll our eyes, don’t record any of the specifics, and let the
episode pass into the lore of “Well, the other day…”
Here’s a
job for the Quality Management teams…
And then
just as I was about to post this I had a thought. Of these three cases only one
is of my personal experience, and that was from over forty years ago. The other two are from the USA. Do we in
the UK still get these sorts of things happing. On reflection nowhere near as
many as used to happen.
Quality management
in action, maybe?
No comments:
Post a Comment