Showing posts with label The Mislabelled Specimen. Show all posts
Showing posts with label The Mislabelled Specimen. Show all posts

16 September 2026 (Wednesday) - Inspections

This appeared on one of the satirical work-related Facebook pages that I follow… but it illustrates something I’ve been banging on about for years. Back in the day the old CPA standards were for most people unobtainable for most of the time.
Everyone knew this, and everyone accepted this.
Back in the day when I was in charge our lab passed with only three (very) minor findings, but it was the result of a lot of hard work to reach a standard for one day which was frankly beyond anyone’s ability to maintain for more than a day. We would put on a show, breathe a sigh of relief when the inspectors went home, and put our feet up for the next four years. After four years we would get plenty of notice of our next inspection, and would again move heaven and Earth to be ready on the day.
The late Duke of Edinburgh unknowingly summed up the old CPA standards when he once remarked that everywhere he went smelled of paint. And the current ISO standards are in much the same vein.
 
As a lad our Boys Brigade entered a team into the fire brigade’s fire safety quiz competition. There we learned about industrial and commercial fire safety standards which were manageable and obtainable…  but the fire brigade would turn up unannounced to check that all was in order.
 
Surely we would be far better off with such a system. Manageable and achievable objectives which are inspected without prior notice.

6 October 2025 (Monday) - A Morphology Quiz

I had another go at The Mislabelled Specimen’s morphology quiz. I got two wrong…
 
The one on the left is a rubricyte. No – I’d never heard of it either. Apparently in some schools of thought red cells progress from rubriblast through prorubricyte, rubricyte and metarubricyte to erythrocyte.
There’s several stages of what I would can a nucleated red cell. I suppose that makes sense.

And the one of the right was my usual error of mistaking a promyelocyte for a myelocyte.
This is a mistake I’ve made before…  
 
But I’ve learned something…

 

30 September 2025 (Tuesday) - The Mislabelled Specimen

I always felt https://themislabeledspecimen.com was just some odd Facebook page. It isn’t. There’s quite a bit to it.
Take this link for example. An on-line morphology quiz. And it is different every time I’ve tried it.

28 July 2024 (Sunday) - Mistakes (Honest and otherwise)

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?