Wrong Blood in Tube Errors: Legal Issues and Recommendations
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Transcript of Wrong Blood in Tube Errors: Legal Issues and Recommendations
Wrong Blood in Tube ErrorsLegal Issues and Recommendations
Angeli Lagasca, RN, BSN, CCRNColumbia University, Teachers CollegeDecember 5, 2014
CASE STUDY
DISCUSSION:
What went wrong in this scenario?
What were some contributing factors?
Were there opportunities to prevent these events?
WHAT IS A WBIT?
W.B.I.T.- WRONG BLOOD IN TUBE- Blood is drawn from Patient A- Sample is labeled with Patient B’s information
WHAT HAPPENS NEXT?
“Near-miss”- Error is caught immediately- No harm is caused to either patient
Unnecessary Treatment- Pt B’s label is used on Pt A’s specimen- Pt B is treated for Pt A’s results
Delayed/Missed Treatment
- Pt A’s irregular results logged as Pt B’s- Pt A is not treated for these results
WHAT’S THE WORST THAT COULD HAPPEN?
INCOMPATIBLE BLOOD TRANSFUSION- Type & screen or cross-match is performed with Pt A’s blood- Testing is logged under Pt B’s lab results- Pt B is transfused with blood which has not been properly matched
=HEMOLYTIC REACTION: SEVERE INJURY, DEATH
CIRCUMSTANCES OF OCCURRENCE
BLOOD SPECIMEN COLLECTION ERROR OCCURS WHEN:
“...Tubes are labeled away from the bedside...the patient's identity is not checked before drawing the blood ...and with the use of preprinted labels"
(AULBACH ET AL., 2010 p. 48)
RISK FACTORS
WBITHUMAN ERRORSYSTEMS ERROR
POOR P&PINADEQUATE EDUCATION
SYSTEMS / EQUIPMENT ISSUESLACK OF SUPPORT FOR STAFF
ANXIETYFATIGUESTRESSFUL SITUATIONSDISTRACTIONSUNFAMILIARITY WITH TASK
LEGAL ISSUES: BREACH OF DUTY?
INDIVIDUAL NONCOMPLIANT WITH P&P?DID NOT MEET STANDARD OF CARE?FAILED TO ASSESS/MONITOR?NO ESCALATION OF CONCERNS?DID NOT ADVOCATE FOR PT SAFETY?
ORGANIZATION RESPONDEAT SUPERIORINADEQUATE P&P?SYSTEMS DID NOT ALLOW FOR COMPLIANCE?POOR RISK MANAGEMENT/QI INVOLVEMENT?
PREVENTION: RISK MANAGEMENT
COLLECT INFORMATIONIncident reporting, chart, interview
I.D. CAUSES, CONTRIBUTING FACTORSIndividual and/or systems errors
ADDRESS AREAS OF VULNERABILITYAdaptive P&P, equipment, education
EVALUATE EFFICACYMeasure compliance, rate of error
PREVENTION: POLICIES
SPECIMEN COLLECTION- Verify patient identity- Match ID band to specimen labels- Affix labels at the bedside
PRETRANSFUSION- Two separate blood samples- Two witnesses at sample collection- Verify identity, affix labels at bedside
IMPLICATIONS: NURSING EDUCATION
ACADEMIC SETTINGS:- PATIENT IDENTIFICATION- PATIENT SAFETY- STANDARD OF CARE
PRACTICE SETTINGS:- CHANGES TO POLICY- OBSERVATION/REMEDIATION
COMMUNICATION!
IN CONCLUSION...
WBIT ERROR IS CAUSED BYA DRIFT FROM THE BASICS:PATIENT IDENTIFICATION!As Nurse Leaders, we can advocatefor patient safety by providingcommunication and supportfor nurses.
QUESTIONS?
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