A Foundation Year 2 (FY2) doctor was working in a large obstetric unit. On a particularly busy night shift, two patients required emergency Caesarean sections and all the rest of the unit's staff were attending other patients. Consequently, the FY2 doctor took blood samples to check the haemoglobin of both patients. As both patients had complicated pregnancies, the unit's protocol was to take samples for group and save. The doctor took the samples from both patients and returned to the ward office to write the haematology request forms and label the sample bottles.
One of the Caesarean sections had been complicated and there was significant blood loss. The patient was advised that a blood transfusion would be necessary, to which she agreed. Having had a sample group and saved, the duty haematology technician duly cross-matched two units of blood, which were delivered to the ward.
Following normal practice, the midwife checked the blood-type of the bags delivered against the known blood group of the patient and was concerned that they were incompatible. The FY2 doctor was contacted and immediately realised that she had almost certainly inadvertently switched the samples that she had taken from the two patients earlier in the evening. Both samples were discarded by the laboratory and fresh samples taken. Despite the modest delay, the patient received her transfusion and there were no ill-effects.
The midwife and F2 doctor jointly reported the adverse incident to the unit manager and a significant event audit was carried out. It was discovered that, although there were mitigating factors, it was inherently risky practice not to label samples immediately after they are taken. The findings of the audit were fed back to the department during educational meetings. The matter was dealt with as a training issue by the Trust and the FY2 doctor went on to successfully complete her post.
The MDU advises doctors to exercise as much care in labelling specimen bottles as in keeping records generally. The General Medical Council, in its 2006 publication Good Medical Practice, advises doctors to keep clear and accurate records and to make them at the same time as events or as soon as possible afterwards. Had these simple guidelines been applied to labelling the sample bottles the adverse incident, or worse, could have been avoided.
This page was correct at publication on 01/05/2009. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.