Sunday, April 20, 2014

Bloody stupid

About 2 or years ago a patient, lets call him Patient A was having surgery at the Big Downtown Hospital (BDH).  For various reasons intraoperatively it was deemed that he needed blood and so the anaesthesiologist drew blood for cross match.  This was put into the appropriate tube and handed to the nurse.  Shortly after, things got better and it was decided that Patient A didn't need blood after all.  The nurse put the tube on a ledge in the operating room.

The next case was Patient B.  Intraoperatively it was decided that Patient B also needed blood.  The nurse (maybe the same one or a different one) saw the tube of blood on the ledge, assumed it had been drawn from Patient B, put Patient B's sticker on it, filled out the appropriate forms and sent the sample to the blood bank.

Fortunately for Patient B when the blood bank ran the blood sample they checked against Patient B's records and discovered that Patient B had not only been typed in the past but that his blood type was different from the sample that was sent to the blood bank which was of course Patient A's blood.

A certain tragedy was averted.

Now there were obviously a few procedural issues about collecting blood samples in the operating room at the BDH that needed to be addressed and certainly the nurse(s) and the anaesthesiologist involved in this case needed to be taken out to the woodshed on this.  Unfortunately we don't take people out to the woodshed anymore when they screw up.  Instead we get bodies like this involved.

Therefore instead of meeting with the individuals involved, presenting this at the local QA committee and developing or reconfirming a policy of properly identifying blood samples drawn in the OR, multiple high paid individuals, mostly removed from clinical practice got to pontificate about this for several weeks and finally arrived at policy, which we we all learned of for the first time when it was announced as a fait accompli.

Henceforth a type and screen done must have a second confirmatory blood sample drawn to check the blood type if the patient has not previous had a blood type. This doesn't just apply to samples drawn in the operating room where this event occurred, but also to samples drawn by the lab, who already have fairly rigourous procedures for identifying patients and labelling samples.  Hematology also announced that rather than routinely collecting this second sample in elective cases that needed it, they would not because they were too busy and that it would anaesthesia's responsibility to collect the second sample (not withstanding the fact that it was anaesthesia drawing a blood sample which caused this problem in the first place).  But don't worry said hematology, if because of time pressure it was not possible to send the second confirmatory sample they would send O negative blood.

This is somewhat moot in that many patients have had a blood type done in the past including every obstetrical patient who has had prenatal care.  Further as the hematologist pointed out to me only a small fraction of patients who get a type and screen actually ever get transfused.  And as he kept repeating, it is not like the patient will not get blood, they will just get O negative blood.

This was not reassuring for me or my colleagues.  Most of us feel that we have enough to do at the beginning of the case without having to check whether the patient has had a previous blood type, draw the blood and fill out the forms.  With newer transfusion guidelines, we let patients bleed down to what were previously considered dangerous hemoglobins which means when we need blood, we need it now.  Most of us consider giving O negative blood a sign of failure, an admission that we were not properly prepared or vigilant enough.  There is also of course the issue of the supply of O negative blood if we are going to be giving it out willy-nilly for purely bureaucratic reasons.  Being O negative myself, I wonder what happens if I get into a car accident driving home from work and there is no O negative blood available because they gave it to other patients.  (The hematologist assured me that as a man it would be perfectly safe for me to get O positive blood).

I have never seen an ABO transfusion reaction in my career, nor am I aware of any in any hospital where I worked.  I have however been in multiple situations where blood was needed and was not immediately available for various reasons and it is sickest feeling mainly because even if it wasn't your fault, you always blame yourself, you should have called earlier etc.

Our hospital's hematologist was very good during all this.  This policy was arrived at with minimal if any consultation of front line physicians.  I watched him come to our department meeting and patiently explain the policy which I could pretty much see he didn't agree with but had to implement.  Some of our guys gave him a rough ride.

Things seemed to have calmed down now after months of shouting matches over the phone between members of my department and the blood bank and we are finding a way to work with this policy.  (I seem to spend a significant amount of time as department head figuring out how to do end runs around stupid policies.)  No one seems to be harmed by it (except for patients getting an extra stick) and nobody seems to be benefiting from it.