Wrong cross match

1. Wrong cross match

2. Dr. Li Tai Wok, CUHK graduate, intern for 9 months, starting on his last shift in surgery (had also applied a job in surgery; inspired to be a hepato-biliary surgeon)

3. Third morning on the house job; 3am • Nurse called him as one of the GIB patients (who was on transfusion) complaint of chills and rigor, pulse was 115/min, BP 95/70; SaO2 92%, RR 30/min, a bit confused as well • He immediately attended the patient and found out there must be something wrong with the patient • He called his on-call MO (who was asleep in the call room); instructed him to stop transfusion and to insert a foley catheter

4. Earlier at 8:30pm; while he was having dinner in canteen • Got called to take a cross match for a GIB patient who had a Hb of 6 and just came back from OGD where adrenaline injection plus heat probe applications were performed. • He asked if he could finish his dinner first and the nurse said “no”. • Trying to show people he would be a good potential surgeon; he went back to the surgical ward with a lot of anger and he start prepare the cross match • He asked the nurse about bed number of the patient (which was 1). He immediately went to the drawer and get the necessary bottle. At the same time at the station, he got three gum labels and stick it onto the forms. Quick enough, he went over to the patient and took the blood. He asked the patient his name and ID no. at the bed side. On his way to the nursing station where he has left the case notes and X-match form, his pager went off again. His quietly said something like “daXX it”. • He then sent off the blood with the form.

5. What has went wrong?

6. Earlier at 8:30pm; while he was having dinner in canteen • Got called to take a cross match for a GIB patient who had a Hb of 6 and just came back from OGD where adrenaline injection plus heat probe applications were performed. • He asked if he could finish his dinner first and the nurse said “no”. • Trying to show people he would be a good potential surgeon; he went back to the surgical ward with a lot of anger and he start prepare the cross match • He asked the nurse about bed number of the patient (which was 1). He immediately went to the drawer and get the necessary bottle. At the same time at the station, he got three gum labels and stick it onto the forms. Quick enough, he went over to the patient and took the blood. He asked the patient his name and ID no. at the bed side. On his way to the nursing station where he has left the case notes and X-match form, his pager went off again. His quietly said something like “daXX it”. • He then sent off the blood with the form.

7. Unlabeled cross match blood sample Take 1

10. Unlabeled cross match blood sample Take 2

11. Dr. TW Li, 3:45am GS intern on call • Dr. Li was on call and he had admitted already 8 patients after 5pm. He was called to clerk in this 85-year-old man who was in shock and have PPU. The admitting MO planned to book emergency laparotomy for this old man. • Dr. Li prepared gum labels for blood taking for X match. • He labeled the transfusion request form and brought along another label to patient’s bedside. He signed the label in advance because he felt inconvenient to write on the label surface after sticking it onto the specimen. • The specimen tube was not labeled at this stage because Dr. Li afraid that it would be contaminated in case of blood spillage. Vacumtainer was not used because he found it difficult to do so. • Before blood taking, Dr. Li performed checking according to identification triangle (check the patient’s name and ID on form, bracelet and label). • After blood taking, he performed checking again. However, he forgot to stick the label onto the specimen tube. • The unlabelled blood specimen was eventually sent out.

12. Unlabeled cross match blood sample Take 3

13. Dr. TW Li, 1pm, pending lunch together with his friend • 27 March 200X • Dr. Lee Oi (Dr. TW Li’s good friend) prepared 5 cross match request forms for cases to be clinically admitted on the following day. Information was filled up but forms were not labeled. • 28 March 200X ~ 1pm • At ~1pm, while Dr Lee was admitting the cases, Dr. TW Li offered help to take blood for one of the patient & requested her to sign a label for specimen. • He brought along the specimen label for blood taking but not the form. He was a little bit frustrated as these patients had delayed his lunch appointment with Dr. Lee. • After blood taking, Dr. Li gave labeled blood specimen to Dr. Lee who attached it to an unlabeled request form for sending out. Dr Lee could not recall the course of action. • They went out for lunch and got a call from blood bank informing her that her labelled blood specimen had been sent off with a form without label. • Lesson to learn – No matter what……Don’t deviate or violate the protocol !

14. Wrong labeling of blood sample Take 1

15. Dr. Li Tai Wok, very busy surgical intern • Dr. Li has the habit of sticking patients’ labels on the sleeve of his white coat. • He was asked to do a cross-match for a patient going for elective liver resection. • Dr. Li took 3 labels from medical record for blood taking for cross-match. He had checked the patient identity of the 3 labels. • He stuck 2 labels onto the form and the remaining one for specimen onto the sleeve of his white coat. • When he approached patient, he performed checking of patient identity of bracelet against request form and label for specimen. • He took blood for patient. • After blood taking, he stuck the label onto the specimen and put it into the plastic bag and then the out-tray for blood collection in the ward. • However, when he stuck the label onto the specimen, he did not check it again and was not aware that he had taken label of another patient which had been stuck on his sleeve. • Later, he was informed by WM of the mistake, he found the correct label on his sleeve and realized that he had taken the wrong one.

16. Wrong labeling of blood sample Take 2

17. It was 2 pm, 2 day patients (LAI & LIU) were admitted for colonoscopy at the same time. Both of them required blood taking for X-match and some laboratory tests. • Dr. Li took medical record of the first patient (LAI) from station to computer desk for printing of GCRS labels. He labeled the X-match request form and stuck the label for X-match specimen onto the surface of a plastic bag which was intended for the X-match specimen. The whole set of labels for patient (LAI) was put on one side of the computer desk. The medical record of this patient was returned to nurses station. • Dr. Li then took medical record of the second patient (LIU) to the computer desk and repeated the whole procedure again. After preparing the second set of labels, he put it on the other side of the computer des • He then took 2 sets of labels to the seminar room (where patients were waiting for beds) for blood taking with each by one hand. • Since patients did not have bracelets somehow, Dr. Li asked the first patient to tell her name and ID and check them against labels. (All specimen labels were correct for the first patient). She checked on the label on the transfusion request form. • Dr. Li proceeded to take blood for the second patient. Same as the first one, she asked patient to state the name and ID, and checked only against the label on transfusion request form. • The X match blood specimen label of the both patients (LAI and LIU) were incorrect.

18. Wrong labeling on the form Take 1

19. Surgical intern – 10AM, not on-call the previous night; slept well (actually had just finished breakfast after ward round) • Dr. Li was handling a number of elective/clinical admission at the nursing station at the same time. • He took medical record of patient A to his bedside for blood taking (Patient A was admitted for TACE). • He labeled the cross match request form at patient bedside. • Before blood taking, he checked patient identity on bracelet and labels for form and specimen. To his surprise, he found the labels was not the same as the information on bracelet. He checked and noticed that labels of two different patients were there in the folder. • He changed the label in form and performed checking again. However, he just changed the label on the front page but forgot to change the one at the back.

20. Take home messages • Follow the protocol straightly; • Don’t violate the protocol or cut corners, and; • No matter what, follow the protocol straightly and you will be fine. Good practice will bring you good luck !