Transfusion Service Supervisor Advocate Christ Medical Center Oak Lawn, Illinois, United States
Background/Case Studies: A manual test was being performed on a pediatric sample due to the specimen not working well on the automated instrument. Results were manually entered into the Laboratory Information System (LIS). A confirmatory blood type was also performed on a second pediatric sample and manually entered. The individual performing testing had history paperwork for the pediatric patient as well as an adult patient sample being tested on automation. Approximately 2 hours after manual results were entered, the “Pending” test list was reviewed and it was discovered that the pediatric patient was still pending. It was at this time that the individual discovered that the paperwork with the adult patient’s barcode had been scanned, and results for pediatric patient were entered manually under the adult medical record. A unit of B Negative RBCs had been issued to the adult patient prior to discovering the manual entry error. The adult blood type was A Positive.
Study
Design/Methods: The blood type for the adult did not transfer from the automation to the LIS because the results were marked as completed. Staff print a specimen label that includes a barcode to place on the patient paperwork. The Pediatric samples that were received were collected in bullet tubes, so it is more difficult to scan the sample label on the bullet tube when manually entering results.
Results/Findings: The floor was notified that the blood for the adult patient should be stopped immediately but more than half of the ABO incompatible unit had been transfused. The patient complained of feeling anxious and had just started having chills and rigors, but clinical team did not call a transfusion reaction. A hemolytic reaction did occur with elevated total bilirubin, LDH and haptoglobin. Post transfusion sample was moderately hemolyzed with a 1+ Direct Antiglobulin Test (DAT). Review of workflow and procedures found that manual test result entry stated to “scan the specimen identification” but did not specify that the specimen should be scanned. Updated process now includes covering or lining through the barcode label that is placed on the paperwork. Manual entry procedure has been updated to call out individual steps of the process rather than a generic “scan the specimen ID” statement. The manual entry process now includes both manual testing and manual entry for automation needed for post downtime recovery.
Conclusions: Although there had never been a previous ABO result entry error, several opportunities were identified during the investigation of this event. Specifically describing the manual entry process along with defacing the barcode on the history paperwork has been implemented in hopes of preventing this type of error from reoccurring. Luckily the patient only had a moderate hemolytic reaction, but we need to prevent this from happening in the future.
