Here’s a couple of random thoughts that occurred
to me whilst walking the dogs round the woods this morning.
I made a mistake at work yesterday. The
mistake was that I thought I got something wrong. I hadn’t.
We had a phone call querying someone’s
blood group. Last week our analyser wasn’t happy with a blood group so I did it
manually and reported it as Rh(D) Positive. However records from way back when
said she was Rh(D) Negative. I felt physically sick… but after a little to-ing
and fro-ing it turned out that samples had gone to the National Blood Service
and she was known to be Rh(D) Positive, albeit with a weak D. I’d actually got
it right.
Back in the day when we did Rh groups we
used to do a DAT on all negative reactions, and if that came out positive they
were called Rh Du Positive. We now know there’s (effectively) a spectrum
of positivity, and the modern antisera pick up more of the weak reacting D.
Which made me think… Back in the day had
we been giving prophylactic anti-D to D-positive people during pregnancy? If so
demonstrably it hadn’t been an issue. Had it?
My second thought was about how I’d
worried yesterday. I had felt physically sick. Fourteen years ago I made a
serious mistake at work. I never did get to the bottom of what happened. All I
can say is that having made a mistake it was used as a way of getting rid of someone
who didn’t always toe management’s line. Without going into details, what followed
that mistake was stressful in the extreme.
But does this mean I am not allowed to
make a mistake ever? Look at any hospital mistake that is ever made. No newspaper
ever reports on tragic mistakes made by overworked staff who are racked with
remorse. But they often talk about the incompetence of bungling medics.
I can remember a discussion about this
very subject when I was doing my IBMS Special exam course in 1987 (MSc
equivalent). Our tutor, the much-missed Pete Chopping asked us how many
babies a midwife could drop.
Obviously he was being facetious, but it
is a valid point.
This is where quality management should
come in to play… I did a course on that last year.
I know I’m worrying over what-if. I
should stop doing that. It does my blood pressure no good.
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