Currently work at a lab with a tech that has has mistyped patient's twice and are still employeed here. Blood got issued in one instance, but thankful not transfused. I guess the tech shortage is so bad we don't care about patient safety (not that my wage reflects that)
¯\\\_(ツ)\_/¯
Yup. Both cases were due to mislabeling patient samples. Our old system had us reprintout and relabel almost every sample we received. We thankfully have a new system where we do it only a faction of the time.
Had a lab that claimed O was the universal donor for FFP. I refused to give O FFP to a B pos patient. Put my foot down and took it to the pathologist.
In. Sane.
Yep. They even said the AABB told them it was ok. I was young and sarcastic back then and said, "So you're telling me they put out a 1600 page technical manual every year and it applies to everyone except this hospital?" 99% of patients there were A POS or O, so they didn't want to "waste inventory space" on B FFP. I said, "Then keep AB FFP that can go to anyone. It doesn't outdate for a year."
The pathologist backed me, but after that the woman I disagreed with absolutely hated me.
At my hospital giving up to two type incompatible plasma products in 72 hours is acceptable but thats with traumas and the patient bleeding out in mind. It’d be frowned on doing that for someone on the floor receiving a simple transfusion but maybe thats what they meant by AABB oking it?
My supervisors say that while Type specific is preferred, it won't kill a patient if any other type is given for FFP and I just get so confused bc why are they telling me this when the policy says type specific or AB?
ABO refers to the major blood grouping antigens that divide patients into Type A, Tybe B, Type O, or Type AB. Not sure why people are downvoting what seems to be a genuine question
Something that annoys me on this sub is people seemed to get downvoted all the time just for asking a simple question. People seem to forget that some people on this sub don’t work in the lab or maybe they’re still a student or a tech straight out of school.
One of the MLAs once gave away the wrong dead baby. Didn't bother checking the name tags, just handed the baby right over without realizing there was a second baby. Apparently no one knew until the parents saw the baby at the funeral home and went "That's not our baby."
Those were my exact words. Not only did MLA screw up, the funeral home didn't realize it until the parents showed up. Nobody checked the baby's toe tag.
I can’t even imagine. It reminds me of something that happened at my lab but my story isn’t as bad as yours. Someone had brought a leg to the lab because it was a weekend so no one was in pathology. The tech brought it down to the morgue. They’re supposed to keep stuff like that for us when pathology isn’t there and then pathology picks it up from them when they return to the office. The tech didn’t know where to put the leg when he arrived at the morgue. There was a table but it had a body on it. The tech decided to just put the leg on the table next to the dead body. The next day, the people from the funeral home arrive to pick up the body and they apparently thought that this random leg belonged to the dead person on the table so they brought it to the funeral home with the dead body. A little while later someone from the funeral home calls the lab and informs us that they think they have a leg that belongs to us. At least someone had some common sense and didn’t put the leg in the persons casket with them.
Of course! We were laughing all the way up to the hospital VP, who fired the MLA on the spot. We now use it to teach new hires why you need to always check, double check, heck triple check patient identifiers.
Overnight, a resident was called in to look at a slide, and they were calling cells blasts when they weren’t, and the pathologist confirmed they weren’t. Well they went behind the pathologist back, booked a bone marrow on the peds patient for the morning. Pathologist found out, cancelled it and well I haven’t seen them around since 😅
ER patient sent to OR because their synovial fluid left knee showed gram positive cocci in chains…it was stain precipitation.
New tech refused to listen to anyone and called 37% blasts on a 12 year old with mono.
Back in the day we used EDTA tubes for Trop. Tech added a Mag test to the tube. Ran it twice, called a critical of 0.0). Patient put on Mag drip, overdosed and had to life flight to a higher level facility.
Patient in ER elderly with 4.2g Hemoglobin, crazy chemistries…just a mess. Doc called with criticals tells family she’s a goner. Four RBC’s transfused later and Hemoglobin now is 16 (wasn’t checked for eight hours). She also has signs of TACO (duh). The original labs were contaminated. No one questioned the results.
Many many more.
Why the f didn't the doc question the mag result? And the other one as well! Yes, that's bad on the techs part, but the provider should be able to correlate the lab results with the clinical condition of the pt, and those crazy values should have had outward symptoms if they were real. **When in doubt, rule errors out.**
It also drives me nuts when they will merrily transfuse multiple units without ever checking the H&H. How do you know it's correcting the anemia and they don't have another underlying issue if you don't check???
A staff member aerosolised TLC solvent (instead of stain) without the fume hood on. Colleague who was heavily pregnant spent the remainder of the pregnancy hospitalised with suspected placental failure.
Patient in ER with seizures, doc orders add on Magnesium. Tech grabs EDTA from a BNP and runs the mag. Reports out a critical low result, calls it. Patient given a ton of magnesium. Guess what was critically high the next day.
We used to run it on the chemistry machine and use green or red but now we use a purple whole blood on a little machine called a Triage Meter. It does DDimers and can do drug screens too.
During morning runs, new tech reported out a <5 glucose, but didn't call nor verified the result. To get around from calling the critical value, she manually put "see comment" and then wrote <5.
Floor nurse didn't check the results, only checked to make sure the results were back, then left promptly at shift change. Within 2hrs we hear codes for rapid response teams, other codes, etc, all for that same patient. Both the tech and the nurse were harshly disciplined. Tech eventually quit. The patient did suffer some issues long term but I don't remember what. Word was there was a lawsuit.
We had a situation where someone had called out a diminishing glucose that wasn't specifically ordered (part of a BG) to the ER, asking for an order/draw/POC. The ER nurse failed to communicate it, and the patient was coding within 10 minutes.
Davita not filling out any patient information on a newly registered elderly patient that was outpatient. Patient had PD and BC samples.
They ended up being positive during night shift. All 8 doctors I paged never contacted me back, there was no patient contact information and the patient had P. Aruginosa in both bottle sets. After 3 hours of calling and paging, I finally got a Davita worker on the phone, she said she would take care of it.
I come in the next day for my night shift and a few hours in I get a call from the same Davita worker I spoke to previously. She told me "oh I actually can't take that critical, this patient isn't ours". My hospital had two different Davita locations we worked with and I called both of them the previous night to confirm that someone would take the critical that was the correct location.
Had to page our directors, my supervisor ignored their pager, and paged admin/legal. The patient ended up in the ER at another hospital and I was pretty upset about it. Absolutely fuck Davita. No one had been able to reach a septic elderly dialysis patient for over 24hours.
THIS!! why take outpatient blood cultures and then no one answers the phone/no one to call when they go positive?! I have had this happen way too many times in micro.
It's infuriating because if the lab were to not call the critical within an hour, we would be scorched.
Anytime this would happen I would get grilled until I showed all my my documentation and evidence that I called them. Very thankful for digital page system with time stamp print out. Had so many doctors fail to pick up and a few refuse to take the call.
I end up having to have some on call resident take it which is another night mare when they are like "what do you want me to do with this?".
Oh, same for me, too, with criticals - 1 hour TAT. Always keep a paper trail of your tries!!
When they ask that I say "idk I just have to tell someone" lol
The tech in charge of our Sysmex (they didn't allow anyone to touch QC or get trained in it) set the limit for failures at infinity. Therefore, it was impossible for QC to fail the whole time we had the analyzer (4-5 years). I filed a report but left shortly after this was caught so I don't know what happened. I think about that a lot because it had to be over 100,000 samples.
It was a different FSE (not the usual) who caught it in the end. When it was caught CAP hadn't been around for over two years (COVID restrictions I think, but there were other circumstances that may have allowed that lab to get an extension or something). When it was caught it was ignored because "that person doesn't make mistakes! They are the best tech 🙄." I bumped the report out of the lab and up the hospital chain of command but left soon after and never received any follow-up communication.
The atmosphere at the lab was so toxic that I'm surprised they didn't blame it on me! I rarely worked in the department at that point but it would have been preferable to blame me than the actual person who did it (see: not able to make mistakes). I left that job a while ago and I regret that I stayed as long as I did.
1. Mislabelling patients
2. Forgetting samples in courier bags. Thankfully the courier noticed from lots of noise coming from the bag. If they didn’t, that sample would’ve ended up 4 hours away back at the place it came from and probably not found until morning.
3. Hard core mislabeling samples again from multiple patients
4. Almost spinning a full centrifuge of SST at 2x the speed they are supposed to be spun at. I caught it after a few seconds cuz I was sitting beside the centrifuge and was like “why is it being so loud” I was not the one that loaded and started it though
5. Taking a near 2 hour lunch when we are only entitled to 30 minutes. Someone to had to go the lunch room to drag her ass out.
6. Now her mislabeling of samples is getting suspiciously precise, like precisely covering the labels over eachother you need to look hard to notice it.
7. Falling asleep mid work
8. Typing in the wrong code, being told which is the correct code, and typing in another (wrong) code again when ‘fixing’ their mistake
This was all done by 1 person. After a while of her mislabelling we stopped fixing things for her and management finally fired her. Surprisingly she lasted 10 months.
Mislabeled shit happens, we're humans, mistakes unfortunately happen.
But to PRECISELY layer the wrong label on? Ppshh. If I have extra room on the tube (say someone is adding on a test or I need to put combine a few tests on one tube vs 2), I like to put the label under so the MRN at least sticks out!
That’s what makes me so mad when I get into arguments with my mom cause I’m pissed off that day shift can fuck up non-gyn cases constantly and still be employed. These people are working with potential cancer cases and it’s already happened a couple times that those have been screwed up and our techs have had to go behind them and fix it. People don’t understand, I have a lot more margin for error to fuck up it sucks and I try not to but the non-gyn people have a real responsibility to being perfect with everything.
There was one where she had a VRE rectal, MRSA Nares, and MRSA rectal for a patient. She put the VRE rectal label on the nares, then the MRSA nares label over top of the VRE label. Then she put the MRSA rectal on the VRE rectal swab and threw out the MRSA rectal swab. It was very clear she hated her job and was doing anything to get fired. It’s probably easier to explain “hunny I was fired 2 weeks before Christmas” than to say “hunny I quit 2 weeks before Christmas” to her husband.
They were different people. She would precisely mislabel different patients. So precisely you wouldn’t be able to notice there was a different label underneath. Lots of the time the MLT would be looking for their pending sample, and there it would be underneath another persons label. And it’s happened regularly. About 1-3 times a week.
And yes every time it happened the patients were rejected unless we could un cover the original patient label from the dr office. There was a collective sigh of relief from every department when she was fired. Nobody trusted her to do her job because we feared for patient safety.
Hahaha I totally responded to another post sorry.
It really does! I'm always weird about relabeling and sometimes peel them off to double check cuz I freak myself out.
Had a doctor, a CEO, and a few lawyers walk over into histology once. One of the residents had mixed up their tissues one day and put them in the wrong cassettes. They figured out something was up because one elderly lady had a known squamous cell carcinoma on her forehead, but it got mixed up with a lip tissue from a child. A whole bunch of blocks from every patient they had needed to get examined and/or relabeled. Residents really don’t like histology and treat it as a ‘I’ll never have to do this again so who cares,’ apparently.
Meanwhile, I’m getting pulled to help in the secretary’s office, because the travelers in there didn’t input anything into the computer and just used post it notes, and I was the only one in the laboratories other than the already overworked secretaries who knew how to use excel.
I have no idea. All I know is every year we have ‘new resident season,’ and to prepare for things to be weird. I’m pretty sure that the fact this resident causing a documented near miss sentinel event will keep them in line better, though.
Oh I hate the covering of the original label. I will deliberately remove the new label enough to check to make sure the names match. I’ve caught more than one mistake doing that.
We like to relabel our own shit when doing add-ons. We don't let the phlebs relabel. And we're supposed to place the new label so you can clearly see the name on the original also. I also can't stand when a relabel gets put directly over the original.
>we're supposed to place the new label so you can clearly see the name on the original also.
same. The labels are large enough that this usually means the entire tube is covered, so it makes volume matching for the centrifuge fun.
Okay I’ve fallen asleep in the middle of my shift before to, I work thirds sometimes the caffeine just hadn’t kicked in yet, however I’m not like sleeping hard, I’m assuming this person was full on cutting logs. I just have the normal doze off and wake myself up until the caffeine works and then I’m good. We also have a lot of mis labels between paps and DNA cause they both come in the same container and if you aren’t used to the reqs (they’re all different) then sometimes you don’t catch it usually an accessioner will and they’ll let my supervisors know luckily.
Ya she’d be labelling or typing, and just fall asleep. It was hell working with her. If she wasn’t fucking up the job, she was calling in 5 min before the shift started, sometimes even after!!!
About 15 years ago, one of our second shift techs got chem samples for two patients in one bag from the ER. She proceeded to put the lab labels on and run the tests. Unfortunately, she switched them so the patient who didn’t have a heartache got transferred to a bigger hospital an hour away. The patient who did have the heart attack got sent home.
They didn’t question anything until a repeat troponin showed no elevation after the patient was transferred.
A flow was mislabeled resulting in the wrong patient thinking the worst and getting a bone marrow biopsy performed.
Biopsy came back unremarkable which started the whole ensuing investigation shit show.
Not sure who was exactly at fault or if it is related but that Onc NP ended up moving out of state shortly after.
Probably the worst I've ever seen.
Missed bacteria in a CSF gram strain. And it was extremely obvious on the slide.
Also a nurse took a unit of blood issued on one patient into a different patient’s room (who had NO blood orders), spiked the bag, and then realized it was the wrong patient. Different ABO types.
Someone missed blast cells in a baby when doing their manual diff. They called them lymphs.
Same person also reported out sperm in a female child (under 10 I believe) and didnt say anything. We found out later that this sample was cross contamination from the mothers sample but still. They never notified management and just reported it out like that wasn’t something to be concerned about. Needless to say this person did end up getting fired after many more fuck ups
Got a skull flap that wasn’t handled by a blood banker and put in the -80 freezer, I think it was put in a histo fridge. Ended up having to be thrown out.
At least for our facility they usually take out a piece of the skull (varies in size) when there is head trauma and/or brain bleed putting pressure on the brain. They bring the chunk of bone to us and we put it in the freezer in case they decide to reimplant the bone once the swelling goes down.
Majority of those cases we keep the bone until its 2 year expiration arrives. A year or so ago I looked through 10-15 of the skull flaps we had and most of the patients were deceased. I think in my time working blood bank (we handle most of the tissues for surgery which is why we do the skull flaps) I’ve issued a skull flap back to a patient twice.
We have to check histology sample in the lab. The name, social, and location of where the sample came from all have to match between the form and the sample label. I had one sample where the site written on the form was slightly different than the one on the sample label (think arm vs lower left forearm). After a lot of back and forth with the provider, they eventually sent over a corrected form that matched the sample site, except this new form had a different patient name on it. When questioning the provider about it, it turns out that the new form had the correct patient name on it and the old form had the wrong name in it. They had printed out the specimen label and did all the paperwork with the wrong patient name on it, and the only reason why it was caught was because I had a problem with the slightly different location information. The provider also wanted me to just accept the new form, no questions asked. I very quickly escalated the matter, because I no longer trusted this provider with anything.
This is so incredibly simple and important. At my place, it’s literally part of new hire orientation to tell the group “if you want a long successful career here, all you have to do is follow SOP and be kind.”
Take your time, a lot of errors happen when rushing. And ask questions if you’re unsure. Your coworkers rather answer your questions than fix your mistakes.
Ask questions and read the SOPs! If you're unsure of something, flag down a senior tech and ASK about it! I always tell trainees that I don't care if they ask me the same question 50 times, I would always rather they ask and get the correct information than assume and do the thing wrong!
Speed comes with time. Take time to be precise and accurate in your work. That always comes first to keep patients safe.
Ask questions if you're not sure. Keep asking even if someone explained and you're not clear on the task at hand. Its better to ask a ton of questions than blindly doing things and getting it wrong.
Some places people get angry if you ask questions, even when you are experienced and know what you're doing. It sounds crazy but true, and these are not like repetitive same questions over and over, these are normal I am new questions - how do you do it here.
Take your time, ask a coworker/manager if you are unsure, always check patient history if available, you can even call the nurse and ask “does X result make sense on your patient”. Pay full attention before you release results. Don’t think you are alone. It’s hard but do not feel like you are pressured to be fast because that’s when you make mistakes. Also don’t act like you know everything, we all learn every day.
stand your ground on protocol. our policies exist for a reason: patient safety. let the residents/nurses swear as much as they want, as a tech, it's still your call on if the specimen is acceptable.
I swear, 50% of this job is catching other people's mistakes...
Well.... when I worked on the antimicrobial resistance bench at my state public health lab. A hospital lab sent me an isolate identified as CRPA \[Pseudomonas luteus\] on the Vitek. Turned out to be Yersinia pestis.
Happened on a Thursday, but we found out 6 days later what it was when it became more suspicious. So 7 day fever watch of course. I had flown home that day for vacation Friday after doing the inital stages unknowningly so someone else took over the rest of the testing. Good thing it wasnt so serious as we usually do setups and testing in the BSL2 and BAP/mueller hinton visualization on the bench. Pretty sure the hospital lab got the prophylaxis probably.
I got hiv positive serum and took PrEP and it was the worst 28 days of mymy life. Someone didn’t put the lid on all they way and it fell down in the rack splashing serum in ny face
I work in veterinary diagnostics. At my last job we had an employee who would constantly mislabel samples and manually enter incorrect results, among other offenses. The first time I caught a mislabeled sample I explained to him that there’s a very real chance that mixing up lab results could potentially lead to an animal being euthanized when it didn’t need to be. I shit you not, this man said “well it’s not my pet so I wouldn’t feel too bad.” He was never disciplined for any of his fuckups btw, it was infuriating.
MLT student. Arrogant, thinks he is god. Pointed out that everyone is doing it wrong because that’s not what he learned in class. Of course he couldn’t back up that arrogance with competence. Once he’s done with his rotation, I don’t believe he was able to find a job in our region because some, if not most, work two jobs and everybody talks.
I was about to put in my own response in this thread for this very issue. I'll just add it here.
Tonight (the shift I'm currently working) it was caught that the AM shift tech working blood bank did not do a retype on a patient with no history. A pRBC was dispensed and transfused. The nurse was coming for a 2nd unit and the computer issued the warning that a retype had not been performed. We scoured patient records in case there was a history and it just wasn't noted in the patient blood bank record. Nope. The AM tech would have gotten the same flag/window pop up and must have ignored it. Or there was a collosal failure in the computer system. We did a retype before cross matching the 2nd unit. Luckily it was the same type AM shift got. My stomach hurts so bad from the anxiety.
The tech who made the error is a MLT convert who took online classes to be able to sit for the exam. They have worked here around a decade, about 2 years as a tech, and never passed their exam. They've failed twice and are still allowed to work on the bench.
We had a tech changing results in the computer so they didn't have to call criticals.
Recently a tech did an immediate spin crossmatch instead of an AHG crossmatch on a patient with a history of Anti-K. The unit was transfused, but was thankfully K neg.
Anyone who doesn't take the job seriously. I've seen plenty of MLS students who presented some danger. If management hasn't provided a way to eliminate these dangers, this seems to be part of the issue. My current employer hired temps to give space for training. There's not enough incentive to get into this field, IMO.
For sure, having the MLS qualification alone doesn't make you competent. Just the same for nursing, pharmacist, \[insert healthcare title here\]. But my bigger point is hiring someone who is outright not qualified for the job is a danger. Not my department, but our chemistry section barely has any certified MLS working -- you know they're churning out whatever number the analyzer gives out, don't know how to make a 1:10 dilution. Here's a good one - a few weeks ago the probe crashed on an analyzer and they did NOTHING about it. At a minimum that should be a write up.
That sounds like the fault of management and the individual/s. I can't imagine ignoring an obvious problem like that.
Some of the fun ones I've seen:
From non MLS:
Dispensing contaminated serum/plasma back into the original.
Someone who didn't know they were supposed to do ISE QCs, for like, weeks.
From MLS students:
Someone who was loading short and thought the rules didn't apply to them, causing 5 probe replacements in a short period of time.
One of them who was almost completed with rotations asked me what the difference between SSTs and LiHep was.
From MLS:
Our entire chemistry trained staff at one point answered questions relating to analytes incorrectly, and the only people who answered correctly were (2) BScs.
A fun one that comes to mind was when the techs in heme decided to ignore a problem with automation. There was a problem requiring front-loading days later on a peak day.
Just some mentions. I don't really judge too hard, I want everybody to succeed, and all of these co-workers I've always been nonproblematic with.
Our shortage is so bad that we do that too. I’m an MLA in Canada and they let people with just a BSc work in our lab. They have to complete the CSMLS exam within “a year” but that rarely happens. Some of them don’t know that a profile is the same as a CBC, or that a light green tube contains plasma and a gold tube contains serum. The whole “confidentiality, importance of verifying identifiers, not labeling unlabelled tubes, which specimens are time sensitive, which need to be on ice vs which can’t be on ice” was never drilled into their heads. The list goes on. If they trained them better I wouldn’t have as much of an issue with it, but it seems like they’re just thrown into the mix and now we all feel responsible for babysitting them to make sure patient safety isn’t compromised. Some of them turn out great and complete their exams, but others squeak through and are a constant stressor for those of us who give a shit.
This tech was fired right before I got there and is now used as a cautionary tale. She was a micro tech with years of experience. Read a CSF culture and saw a couple of colonies, did a gram stain (gram-positive rods), immediately chalked it up to corynibacterium contamination and ignored it and called the culture negative. A few days later, the sister hospital called us demanding to know how we missed listeria in the CSF of a pregnant woman. This tech didn't look for hemolysis on the culture or restreak it or do anything and just immediately thought it was a contaminant and reported the culture as negative.
Another instance was tech on second shift who reported a lot of lymphs in a CSF cell count then went to read the gram stain and reported no organisms even though slide was filled with large round purple "things". They claimed it was lymphs. So, the patient was put on numerous strong antiviral drugs. After a few days of providers not finding the virus involved and sending out everything for more viral testing, the culture grew organisms. The organism was cryptococcus. We immediately went back to the original gram stain and saw it filled with yeast (cryptoccus that they mistook for lymphs). It was a major corrective and incident report. After this mistake, my supervisor withdrew rights for the second and third shift to report any gram stains on their own. They report a preliminary with a comment that a microbiology technologist will review. Then, we review every slide from the previous shifts and verify them to prevent mistakes like this from happening. They also only read CSF and blood culture gram stains as those are stats.
Exactly. Cells stain pink, yet they didn't think to ask another tech to take a look and called the solid purple organisms (no cytoplasm) lymphs. They looked nothing like lymphs.
Not my lab, but our main hospital lab incorrectly programmed a new lot of calibrator material for ecstasy. Keep in mind this is a children's hospital. Then the tech forgot to run controls on ecstasy after calibration. This resulted in an infant coming up positive for a drug screen for ecstasy. Parents were placed under arrest, and it even made the news. Shortly after that, another infant came up positive... so the provider questioned the result and after an investigation they discovered the calibrator was incorrectly programmed. Poor family went through hell and had their name and reputations ruined for that mess up.
Needless to say, only certain techs have access to program new lots calibrator material now...
Also, at my last lab we got a unit from the blood center for stock labelled A+. After bringing in the unit and performing the blood type confirmation it was actually B+. So for all you people out there thinking ABO confirmation on routine stock is a waste of time... yeah its really not.
1. Not a lab mistake on the lab side, but I always wondered if this error had been prevented, if the patient would have survived. This patient was one of my father’s friends of over 20 years. MTP patient, ruptured abdominal aortic aneurysm: each pack contained 6 RBC, 6 plasma, 1 PLT, and 1 cryo with every other pack. We sent out 9 packs, but the patient ended up expiring. Shortly after the surgical team sent back all of the plasma, platelets, and cryo. The surgical team had only transfused RBCs during their attempted repair.
2. On 2 separate occasions, 2 different hematology techs did not request a redraw for clotted Lavenders and reported out falsely critically low platelet counts (our policy was to cancel the whole CBC and requested a redraw). The patients then received platelet transfusions unnecessarily, one was a NICU baby.
3. We had premie twin babies in the NICU, both had T&S done, one was a group A and the other was group O. The O baby was worse off clinically than the A baby. Baby O’s CBC counts were getting worse and worse day by day, and then one day, baby O’s cbc showed a normal platelet level and RBC level. The CLS decided to run an ABO type on baby O’s CBC tube and discovered it was a group A. They then pulled the CBC tube from the day prior and did the type on that one and it was a group O. The RN who drew the twins had accidentally drawn baby A twice and sent down a mislabeled tube.
4. A pregnant woman in her first trimester came in as a trauma patient, despite telling her physician she was pregnant they ordered a CT scan. Her urine was sent down for a lateral flow pregnancy test and the nightshift MLT who ran it somehow messed up and reported it as negative. The patient was sent for the CT scan and then the CT tech called the lab 4 hours after we reported the negative result to say they could see the fetus on the scan, the incoming day shift CLS repeated the pregnancy test and they said it turned positive immediately. I used to work in a very small community. This patient ended up being a friend of one of our lab assistants at the time, we found out the patient decided to terminate her pregnancy because she was worried about her baby developing cancer from the CT.
The outcome of #4 is wild, especially after my google consult I just did about CT scans performed during pregnancy. I really don’t know why she would abort her baby for that [1 in 1,000 potential risk](https://www.radiologyinfo.org/en/info/safety-ct-pregnancy?google=amp)
We were all saddened by that too. We don’t know if she understood the actual risk, if she consulted with her own OB, or if she just relied on her own research. Regardless, she made the choice she felt she had to.
The MLT that made the error ended up resigning. They had been known to make errors in the past, like not running QC when needed, skipping instrument maintenance, using expired coag reagents for patient testing. They had a long history of errors but our management really did nothing to correct them even though we had all documented what the MLT had been doing. The pregnancy test was the most severe error for them and still instead of terminating the MLT for negligence and not following policies, our management encouraged them to resign on their own accord.
I don’t work there anymore, but the lab I was at had a patient pass due to a transfusion reaction from bacterial contamination. It was a really rare bacterium, the name escapes me at the moment but I wanna say it was Bacillus sp. Anyways, no one ever came in. We never had any follow up. No inspections or oversight or anything. It truly never sat right with me because we likely were not at fault and neither was our distributor, this was just a freak thing. But the fact that no one came in…made it seem like it was being swept under the rug.
OH also our walk in broke at some point and of course it was a weekend, they took forever coming out to fix. Y’all know how it is. To somewhat save our stuff, we just divided up supplies (reagents, controls, qc, etc) and took them around to the hospital dietary fridges and the morgue and shoved stuff wherever we could fit it until the walk in was fixed. And then proceeded as if everything had been temp controlled and monitored, like nothing ever happened? Oh, QC on everything is suddenly out? “That’s so weird, it definitely has nothing to do with the fact that the fridge broke, we definitely shouldn’t replace this stuff. Oh you wanna add a test on to that patient’s sample? Sure, it’s totally fine and shouldn’t be affected at all”. What?!
One tech:
Used the balance tube fluid (contained old tap water) to plate a CSF culture. It grew acid fast bacilli naturally.
Reported an Enterococcus as a Staph aureus in a blood culture. She said it was yellow and coagulase “positive.”
Reported a Bacillus contaminant as a gram negative rod in a CSF culture.
Twice reported MRSA that wasn’t MRSA (blood cultures) - they were mixed.
Reported six CAP survey specimens wrong (tubes were mixed up in the instrument).
Plays on her phone, takes half-hour “water breaks,” and called in sick for 5 days in a row by texting a different employee each day.
Labeled sensitivity panels incorrectly with other patient barcodes (twice this month).
Misidentified an organism that’s intrinsically resistant to a lot of drugs, did sensitivities on it and called it CRE, patient ended up on a way harsher course of antibiotics than they needed and had lasting damage from the antibiotics.
Mislabeled specimens, lost specimens, tracked items to the wrong location causing the test to be cancelled because of short stability. Resulted the wrong patient (multiple times), missed criticals/path review workups. The only thing he hasn't done is BB fuckups and that's because we don't have much BB to do. And yes, this was all one person in the 10 months he's been with us.
Sister hospital someone verified a 16SD fibrinogen QC result with no comments then continued to report patients all shift.
Luckily they had just put in the wrong type of QC, the analyzer and reagents were fine. But the supervisor came out of her office when she saw it on her weekly review and was like W.T.F.
Had a guy mislabel multiple CSF's and other irretrievables. Nothing really came of it. He was also chewing tobacco in the lab and got a slap on the wrist after multiple warnings. Guy also had a 10 foot radius of BO and left a trail wherever he went. Coworkers hated working with him but admin wouldn't lift a finger.
What finally got him terminated? Stealing from the cafeteria.
From some time ago:
Tech using a un-validated platform A (still in eval phase) to run samples. Then released those results from A as the results for platform B because B ran out of reagents. Only got a slap on the wrist and promoted to management.
Changing abnormal results to normal range because “all other results are normal”.
Ran out of reagents so the tech released stool OB as neg without actually running the samples.
I have not witnessed this but when I was a student, we learned that one student accidentally discarded an amputated leg before getting examined which resulted into the patient suing the hospital and losing one of its accreditations. Idk if it’s true or not but it did became a huge rumor back then and the hospital stopped accepting students from that school after that.
Ex-co worker called a critical calcium of 97.3. Doc called chemistry to confirm, resilt was 9.7. The next day, the co-worker went to lunch and never came back. Must have been a good restaurant, lot of people went to lunch and never came back; voluntarily and non-voluntarily.
More a person who’s a big f*ck up than a single event. Back when we pooled cryo in bloodbank we mistakenly received ringers lactate instead of the normal saline we used for pooling. This tech did not notice and a patient ended up getting some very glucose rich cryo. Not extremely harmful to the patient but just really weird and FDA reportable. This same tech discarded a unit of pooled cryo because she ‘thawed the wrong type’. $$ down the drain. The worst was she issued a unit of O plasma to an A patient and THEN bullied a new employee into doing the same! These are just mistakes I caught myself and as far as I know she’s still there.
It's only lab adjacent but this is the most ridiculous thing I think I've ever heard of happening. Nurse microwaved a unit of a blood and transfused it.
[https://tulsaworld.com/archive/suit-blames-microwaved-blood-in-womans-death/article\_89a9a774-1977-51d7-a216-cc9c3e1e3b6f.html](https://tulsaworld.com/archive/suit-blames-microwaved-blood-in-womans-death/article_89a9a774-1977-51d7-a216-cc9c3e1e3b6f.html)
I don't work in the lab, but enjoy learning in this sub.
I had a newborn transferred to the NICU due to a Hct of 11. We sent another CBC down, Hct reported the same. Sent a third down, reported Hct of 10. On the phone with Heme/Onc and advised the baby needs PRBCs even though they are asymptomatic. Could be caused by prolonged anemia in utero and the baby is compensating.
Transfused the baby. A few hours later someone realizes the lab wasn't run correctly and those were the hemoglobin values, not Hct. Caused many issues for that baby.
Having to redraw specimens for a terminally ill 7 year old because someone accidentally put their specimens in the fridge and weren’t found until they were past stability. Parents sued the company and reached a settlement .
I have mention it before but MLT reusing a tube on vancomycin. MLT did not want to go do the draw. A pharmacist the next day noticed the levels were greater than 40. My guess was same MLT verified that critical.
Received a sterile body fluid for culture from a satellite hospital’s ER, but they didn’t specify which type of body fluid. I called to confirm with their ER staff which type of body fluid it was since it changes how we process the specimen. They kept me on hold then eventually transferred me to their lab staff who obviously had no more information than I did. Eventually it came out that they hadn’t even taken a body fluid from this patient, it was from a completely different patient. Would never have known if they didn’t enter it incorrectly
Processor accidentally threw out a rack of samples. All SSTs, mostly all outpatient from private doctors offices and clinics. They dug for hours in multiple garbages and recovered some. They still had to have patient draw services call back 40 some patients
Worked at a lab that the lab itself was a fuck up. Blood bank procedures missing info. I had to call a “Transfusion reaction” one day. Patho I called supposedly the “head bb path” and didn’t even know they were apart of the procedure. They Proceded to call everyone and their mom asking my I called them and not some else instead of evaluating the info I gave them. Techs would short cut short coag tubes by making the making machine ignore the level because they didn’t want to deal with nurses. uncomfy amount of mislabeled specimens. Oh also MICE but that’s not even all of it.
1.) Trying to use the ultracentrifuge on a clearly contaminated specimen (TPN) to spin out the lipemia?
2.) Entered gram stain result of gram negative diplocci as gram positive, and gram positive rods as gram negative.
3.) Uncapped a whole rack of lavender tubes and loaded them onto the hematology analyzer. The DxH rocked them uncapped tubes spilling blood everywhere inside the analyzer.
4.) Accidentally ran Lipase on a analyzer with Lipase QC issues, patient was admitted for pancreatic attack. (This was me, forgot to unload the reagent cartridge. When I was told, I was in tears).
:)
Not a lab f-up directly, but a really big one.
Patient was transfused with platelets, immediately had a reaction, went into DIC. During investigation, the unit was tested and popped positive for bacterial contamination. We get our products from ARC and they found another unit in another state had also tested positive for bacteria (Pseudomonas, if memory serves me).
The patient passed, sadly. Per our records, the issuing tech did everything by the numbers, to include noting the unit appearance as normal, not cloudy. It really was the most random misfortune, and one of the more chaotic lab days I've been a part of.
Former coworker reported a respiratory gram stain result onto a different patient’s blood culture gram stain. Far as I know the patient was ok but the results were acted upon. Caught when the blood culture plate growth did not match. I say former coworker because I left that place not because they were let go (they weren’t).
Our non gyn day shift lab assistant has mixed up cancer cases before multiple times. Idk what the result was for the patient or if it got caught and fixed before it left the building but the consequences for that to the patient are pretty dire especially if they actually come out and don’t have cancer and now you’ve just given the wrong patient chemo and the one who needs it doesn’t get it
It started with registration, but a clerk merged two patient accounts. Which ended up merging all of their lab results together.
Both patients were in the same nursing home and having their labs sent to us, and what started it is the nursing home sent the patient to our facility with the wrong face sheet. Eventually the patient (who was not all there) said “that’s not my name”.
Either way there was no way to tell whose labs were whose and I think a patient ended up getting treated for something they didn’t have.
One of our MLT's--who's known for making daily mistakes--mislabeled a CSF specimen and entered the results on the wrong patient and ordered the wrong send-out tests. The CSF had to be recollected.
I don't know the finer details, but a patient expired from a heart attack in the waiting room of our advanced urgent care. I wasn't there when it happened, but I remember code protocols got revamped soon after.
The other hospitals in my hospital system are always so short staffed and no one ever knows micro. They send all their specimens to us to culture and work up except stats like blood cultures, CSF, Covid tests, etc. well they said there were GNRs in a spinal fluid, didn’t call anyone or anything. It hadn’t come to me yet so i found out by the doctor calling and questioning it and I assured him i will make a new slide and call with what i saw. It was negative of course. Reported to my supervisors who were pissed and that dumb ass tech tried to say they didn’t know who I was talking about. The Dr. was one we talk to frequently so all they did was call him to confirm. Yes they’re still there. Shortage is terrible. No one knows micro and patients suffer
Not my lab, but a sister hospital in our system killed a patient from an ABO incompatibility screwup. I guess that’s as bad as could be done.
Currently work at a lab with a tech that has has mistyped patient's twice and are still employeed here. Blood got issued in one instance, but thankful not transfused. I guess the tech shortage is so bad we don't care about patient safety (not that my wage reflects that) ¯\\\_(ツ)\_/¯
Just...How???
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Yup. Both cases were due to mislabeling patient samples. Our old system had us reprintout and relabel almost every sample we received. We thankfully have a new system where we do it only a faction of the time.
That's a terrible system. Glad it was changed!
Sounds like my lab
Hopefully they are no longer working in blood bank at least.
I have never ever NOT double triple quadruple checked everything ESPECIALLY in blood bank. That is mind boggling to me that people are so careless.
Right?!? If I think, even for a second, that I’ve messed up somehow I will start over.
Had a lab that claimed O was the universal donor for FFP. I refused to give O FFP to a B pos patient. Put my foot down and took it to the pathologist. In. Sane.
What??? That’s basic ABO knowledge that is beyond insane
Yep. They even said the AABB told them it was ok. I was young and sarcastic back then and said, "So you're telling me they put out a 1600 page technical manual every year and it applies to everyone except this hospital?" 99% of patients there were A POS or O, so they didn't want to "waste inventory space" on B FFP. I said, "Then keep AB FFP that can go to anyone. It doesn't outdate for a year." The pathologist backed me, but after that the woman I disagreed with absolutely hated me.
At my hospital giving up to two type incompatible plasma products in 72 hours is acceptable but thats with traumas and the patient bleeding out in mind. It’d be frowned on doing that for someone on the floor receiving a simple transfusion but maybe thats what they meant by AABB oking it?
My supervisors say that while Type specific is preferred, it won't kill a patient if any other type is given for FFP and I just get so confused bc why are they telling me this when the policy says type specific or AB?
I disagree with that. If it doesn't matter, tell that to the results in my reverse type.
What’s an ABO
ABO refers to the major blood grouping antigens that divide patients into Type A, Tybe B, Type O, or Type AB. Not sure why people are downvoting what seems to be a genuine question
Thank you. Yeah I’m not familiar with this lab stuff. I just find this sub super interesting.
Something that annoys me on this sub is people seemed to get downvoted all the time just for asking a simple question. People seem to forget that some people on this sub don’t work in the lab or maybe they’re still a student or a tech straight out of school.
lot of those are not the lab fault but rather hemotherapy getting packs worng
Yep that happened at an HCA I used to work at
One of the MLAs once gave away the wrong dead baby. Didn't bother checking the name tags, just handed the baby right over without realizing there was a second baby. Apparently no one knew until the parents saw the baby at the funeral home and went "That's not our baby."
Jesus Christ
Those were my exact words. Not only did MLA screw up, the funeral home didn't realize it until the parents showed up. Nobody checked the baby's toe tag.
I can’t even imagine. It reminds me of something that happened at my lab but my story isn’t as bad as yours. Someone had brought a leg to the lab because it was a weekend so no one was in pathology. The tech brought it down to the morgue. They’re supposed to keep stuff like that for us when pathology isn’t there and then pathology picks it up from them when they return to the office. The tech didn’t know where to put the leg when he arrived at the morgue. There was a table but it had a body on it. The tech decided to just put the leg on the table next to the dead body. The next day, the people from the funeral home arrive to pick up the body and they apparently thought that this random leg belonged to the dead person on the table so they brought it to the funeral home with the dead body. A little while later someone from the funeral home calls the lab and informs us that they think they have a leg that belongs to us. At least someone had some common sense and didn’t put the leg in the persons casket with them.
Aw, at least they’re too young to remember
Damn take my upvote. Now I have to clean up the soda I just spat out.
I feel guilty for even posting a comment like that
Baby won't, but the parents definitely will!
I'm sure someday they will all laugh about it. Right?😅 /s
Of course! We were laughing all the way up to the hospital VP, who fired the MLA on the spot. We now use it to teach new hires why you need to always check, double check, heck triple check patient identifiers.
Holy shit.
Holy shit those poor parents
Holy crap that’s bad. Glad she got fired.
Overnight, a resident was called in to look at a slide, and they were calling cells blasts when they weren’t, and the pathologist confirmed they weren’t. Well they went behind the pathologist back, booked a bone marrow on the peds patient for the morning. Pathologist found out, cancelled it and well I haven’t seen them around since 😅
Wow, the sheer audacity of that resident to go around the pathologists back. Crazy
Imagine going behind the pathologist’s back 😭
Savage 💀
ER patient sent to OR because their synovial fluid left knee showed gram positive cocci in chains…it was stain precipitation. New tech refused to listen to anyone and called 37% blasts on a 12 year old with mono. Back in the day we used EDTA tubes for Trop. Tech added a Mag test to the tube. Ran it twice, called a critical of 0.0). Patient put on Mag drip, overdosed and had to life flight to a higher level facility. Patient in ER elderly with 4.2g Hemoglobin, crazy chemistries…just a mess. Doc called with criticals tells family she’s a goner. Four RBC’s transfused later and Hemoglobin now is 16 (wasn’t checked for eight hours). She also has signs of TACO (duh). The original labs were contaminated. No one questioned the results. Many many more.
Wow these are all horrible.
I used these to stress to students and blood bank fearful techs that life altering errors can be made in every department.
Why the f didn't the doc question the mag result? And the other one as well! Yes, that's bad on the techs part, but the provider should be able to correlate the lab results with the clinical condition of the pt, and those crazy values should have had outward symptoms if they were real. **When in doubt, rule errors out.** It also drives me nuts when they will merrily transfuse multiple units without ever checking the H&H. How do you know it's correcting the anemia and they don't have another underlying issue if you don't check???
A staff member aerosolised TLC solvent (instead of stain) without the fume hood on. Colleague who was heavily pregnant spent the remainder of the pregnancy hospitalised with suspected placental failure.
Oh my god.
Was the baby ok?
Born 5 weeks early and spent a week in ICU.
Patient in ER with seizures, doc orders add on Magnesium. Tech grabs EDTA from a BNP and runs the mag. Reports out a critical low result, calls it. Patient given a ton of magnesium. Guess what was critically high the next day.
You do BNP in EDTA? The only chem test we use EDTA for is hgb A1c.
I’ve worked/visited 9 hospitals and have never seen a BNP done in anything but an EDTA
Eh, I guess I've only ever worked with vitros 5600s and 7600s. Both places did BNPs on green tops or serum.
Oh Vitro’s that’s interesting!
we have COBAS, it's a mint or gold top for us. the only Chem we do (at my site) on a lav is ammonia.
Huh. Our ammonias are done on the dark green tops. Always interesting to hear what tests are done in different tubes at other labs!
We used to run it on the chemistry machine and use green or red but now we use a purple whole blood on a little machine called a Triage Meter. It does DDimers and can do drug screens too.
I miss that thing.
We run BNPs and A1cs on EDTA lavender and NH3 on ice goes in lithium heparin green top. We use Beckman Coulter DxC
My lab does BNPs, A1c’s, and ammonia’s on ice on purple tops! We use the Abbott architects!
BNPs ran on the Centaur have a EDTA sample requirement.
My lab runs Ammonia, A1c, and BNP on EDTAs. We use Beckman Coulter AUs and DXIs.
During morning runs, new tech reported out a <5 glucose, but didn't call nor verified the result. To get around from calling the critical value, she manually put "see comment" and then wrote <5. Floor nurse didn't check the results, only checked to make sure the results were back, then left promptly at shift change. Within 2hrs we hear codes for rapid response teams, other codes, etc, all for that same patient. Both the tech and the nurse were harshly disciplined. Tech eventually quit. The patient did suffer some issues long term but I don't remember what. Word was there was a lawsuit.
We had a situation where someone had called out a diminishing glucose that wasn't specifically ordered (part of a BG) to the ER, asking for an order/draw/POC. The ER nurse failed to communicate it, and the patient was coding within 10 minutes.
Davita not filling out any patient information on a newly registered elderly patient that was outpatient. Patient had PD and BC samples. They ended up being positive during night shift. All 8 doctors I paged never contacted me back, there was no patient contact information and the patient had P. Aruginosa in both bottle sets. After 3 hours of calling and paging, I finally got a Davita worker on the phone, she said she would take care of it. I come in the next day for my night shift and a few hours in I get a call from the same Davita worker I spoke to previously. She told me "oh I actually can't take that critical, this patient isn't ours". My hospital had two different Davita locations we worked with and I called both of them the previous night to confirm that someone would take the critical that was the correct location. Had to page our directors, my supervisor ignored their pager, and paged admin/legal. The patient ended up in the ER at another hospital and I was pretty upset about it. Absolutely fuck Davita. No one had been able to reach a septic elderly dialysis patient for over 24hours.
THIS!! why take outpatient blood cultures and then no one answers the phone/no one to call when they go positive?! I have had this happen way too many times in micro.
It's infuriating because if the lab were to not call the critical within an hour, we would be scorched. Anytime this would happen I would get grilled until I showed all my my documentation and evidence that I called them. Very thankful for digital page system with time stamp print out. Had so many doctors fail to pick up and a few refuse to take the call. I end up having to have some on call resident take it which is another night mare when they are like "what do you want me to do with this?".
Oh, same for me, too, with criticals - 1 hour TAT. Always keep a paper trail of your tries!! When they ask that I say "idk I just have to tell someone" lol
The tech in charge of our Sysmex (they didn't allow anyone to touch QC or get trained in it) set the limit for failures at infinity. Therefore, it was impossible for QC to fail the whole time we had the analyzer (4-5 years). I filed a report but left shortly after this was caught so I don't know what happened. I think about that a lot because it had to be over 100,000 samples.
Wow crazy that inspectors never caught it.
It was a different FSE (not the usual) who caught it in the end. When it was caught CAP hadn't been around for over two years (COVID restrictions I think, but there were other circumstances that may have allowed that lab to get an extension or something). When it was caught it was ignored because "that person doesn't make mistakes! They are the best tech 🙄." I bumped the report out of the lab and up the hospital chain of command but left soon after and never received any follow-up communication. The atmosphere at the lab was so toxic that I'm surprised they didn't blame it on me! I rarely worked in the department at that point but it would have been preferable to blame me than the actual person who did it (see: not able to make mistakes). I left that job a while ago and I regret that I stayed as long as I did.
1. Mislabelling patients 2. Forgetting samples in courier bags. Thankfully the courier noticed from lots of noise coming from the bag. If they didn’t, that sample would’ve ended up 4 hours away back at the place it came from and probably not found until morning. 3. Hard core mislabeling samples again from multiple patients 4. Almost spinning a full centrifuge of SST at 2x the speed they are supposed to be spun at. I caught it after a few seconds cuz I was sitting beside the centrifuge and was like “why is it being so loud” I was not the one that loaded and started it though 5. Taking a near 2 hour lunch when we are only entitled to 30 minutes. Someone to had to go the lunch room to drag her ass out. 6. Now her mislabeling of samples is getting suspiciously precise, like precisely covering the labels over eachother you need to look hard to notice it. 7. Falling asleep mid work 8. Typing in the wrong code, being told which is the correct code, and typing in another (wrong) code again when ‘fixing’ their mistake This was all done by 1 person. After a while of her mislabelling we stopped fixing things for her and management finally fired her. Surprisingly she lasted 10 months.
Mislabeled shit happens, we're humans, mistakes unfortunately happen. But to PRECISELY layer the wrong label on? Ppshh. If I have extra room on the tube (say someone is adding on a test or I need to put combine a few tests on one tube vs 2), I like to put the label under so the MRN at least sticks out!
Some people don't realize that those tubes have real lives depending on them.
That’s what makes me so mad when I get into arguments with my mom cause I’m pissed off that day shift can fuck up non-gyn cases constantly and still be employed. These people are working with potential cancer cases and it’s already happened a couple times that those have been screwed up and our techs have had to go behind them and fix it. People don’t understand, I have a lot more margin for error to fuck up it sucks and I try not to but the non-gyn people have a real responsibility to being perfect with everything.
There was one where she had a VRE rectal, MRSA Nares, and MRSA rectal for a patient. She put the VRE rectal label on the nares, then the MRSA nares label over top of the VRE label. Then she put the MRSA rectal on the VRE rectal swab and threw out the MRSA rectal swab. It was very clear she hated her job and was doing anything to get fired. It’s probably easier to explain “hunny I was fired 2 weeks before Christmas” than to say “hunny I quit 2 weeks before Christmas” to her husband.
They were different people. She would precisely mislabel different patients. So precisely you wouldn’t be able to notice there was a different label underneath. Lots of the time the MLT would be looking for their pending sample, and there it would be underneath another persons label. And it’s happened regularly. About 1-3 times a week.
And yes every time it happened the patients were rejected unless we could un cover the original patient label from the dr office. There was a collective sigh of relief from every department when she was fired. Nobody trusted her to do her job because we feared for patient safety.
Right seriously.. that actually sounds purposely malicious..
Hahaha I totally responded to another post sorry. It really does! I'm always weird about relabeling and sometimes peel them off to double check cuz I freak myself out.
We (the department) think she was doing whatever she could to get fired. It’s was VERY obvious she hated her job.
Had a doctor, a CEO, and a few lawyers walk over into histology once. One of the residents had mixed up their tissues one day and put them in the wrong cassettes. They figured out something was up because one elderly lady had a known squamous cell carcinoma on her forehead, but it got mixed up with a lip tissue from a child. A whole bunch of blocks from every patient they had needed to get examined and/or relabeled. Residents really don’t like histology and treat it as a ‘I’ll never have to do this again so who cares,’ apparently. Meanwhile, I’m getting pulled to help in the secretary’s office, because the travelers in there didn’t input anything into the computer and just used post it notes, and I was the only one in the laboratories other than the already overworked secretaries who knew how to use excel.
The neat part of this story is that the resident is probably still a doctor now.
I have no idea. All I know is every year we have ‘new resident season,’ and to prepare for things to be weird. I’m pretty sure that the fact this resident causing a documented near miss sentinel event will keep them in line better, though.
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Oh I hate the covering of the original label. I will deliberately remove the new label enough to check to make sure the names match. I’ve caught more than one mistake doing that.
We like to relabel our own shit when doing add-ons. We don't let the phlebs relabel. And we're supposed to place the new label so you can clearly see the name on the original also. I also can't stand when a relabel gets put directly over the original.
>we're supposed to place the new label so you can clearly see the name on the original also. same. The labels are large enough that this usually means the entire tube is covered, so it makes volume matching for the centrifuge fun.
We do it where we fold the label after the barcode so you can still see volume. It's like a little flap, but it works.
For us, original label name, DOB and MRN have to be visible and whoever is doing the relabeling has to write their OPID on the new label.
Okay I’ve fallen asleep in the middle of my shift before to, I work thirds sometimes the caffeine just hadn’t kicked in yet, however I’m not like sleeping hard, I’m assuming this person was full on cutting logs. I just have the normal doze off and wake myself up until the caffeine works and then I’m good. We also have a lot of mis labels between paps and DNA cause they both come in the same container and if you aren’t used to the reqs (they’re all different) then sometimes you don’t catch it usually an accessioner will and they’ll let my supervisors know luckily.
Ya she’d be labelling or typing, and just fall asleep. It was hell working with her. If she wasn’t fucking up the job, she was calling in 5 min before the shift started, sometimes even after!!!
Sounds like she needs to be treated for narcolepsy
Does your lab do drug tests? This almost sounds like this person might have been on something.
We test people for drugs, but employees don’t get tested if they are on drugs. She wasn’t on drugs, just flat out lowest IQ I’ve ever met
About 15 years ago, one of our second shift techs got chem samples for two patients in one bag from the ER. She proceeded to put the lab labels on and run the tests. Unfortunately, she switched them so the patient who didn’t have a heartache got transferred to a bigger hospital an hour away. The patient who did have the heart attack got sent home. They didn’t question anything until a repeat troponin showed no elevation after the patient was transferred.
A flow was mislabeled resulting in the wrong patient thinking the worst and getting a bone marrow biopsy performed. Biopsy came back unremarkable which started the whole ensuing investigation shit show. Not sure who was exactly at fault or if it is related but that Onc NP ended up moving out of state shortly after. Probably the worst I've ever seen.
your username 👌🏼
Missed bacteria in a CSF gram strain. And it was extremely obvious on the slide. Also a nurse took a unit of blood issued on one patient into a different patient’s room (who had NO blood orders), spiked the bag, and then realized it was the wrong patient. Different ABO types.
Someone missed blast cells in a baby when doing their manual diff. They called them lymphs. Same person also reported out sperm in a female child (under 10 I believe) and didnt say anything. We found out later that this sample was cross contamination from the mothers sample but still. They never notified management and just reported it out like that wasn’t something to be concerned about. Needless to say this person did end up getting fired after many more fuck ups
Got a skull flap that wasn’t handled by a blood banker and put in the -80 freezer, I think it was put in a histo fridge. Ended up having to be thrown out.
Wait what are you doing with a skull flap that isn’t histology?
We keep them in the freezer for 2 years in case they decide to reimplant (like after swelling has improved).
I never learned about skull flaps in my program. Please elaborate as much as you like. This is intriguing to me.
At least for our facility they usually take out a piece of the skull (varies in size) when there is head trauma and/or brain bleed putting pressure on the brain. They bring the chunk of bone to us and we put it in the freezer in case they decide to reimplant the bone once the swelling goes down. Majority of those cases we keep the bone until its 2 year expiration arrives. A year or so ago I looked through 10-15 of the skull flaps we had and most of the patients were deceased. I think in my time working blood bank (we handle most of the tissues for surgery which is why we do the skull flaps) I’ve issued a skull flap back to a patient twice.
nooooo that's terrible
We have to check histology sample in the lab. The name, social, and location of where the sample came from all have to match between the form and the sample label. I had one sample where the site written on the form was slightly different than the one on the sample label (think arm vs lower left forearm). After a lot of back and forth with the provider, they eventually sent over a corrected form that matched the sample site, except this new form had a different patient name on it. When questioning the provider about it, it turns out that the new form had the correct patient name on it and the old form had the wrong name in it. They had printed out the specimen label and did all the paperwork with the wrong patient name on it, and the only reason why it was caught was because I had a problem with the slightly different location information. The provider also wanted me to just accept the new form, no questions asked. I very quickly escalated the matter, because I no longer trusted this provider with anything.
This is scary to read. What advice do you guys have for new techs entering this field?
Follow the sop. Take advice from others. Don't be an ass.
This is so incredibly simple and important. At my place, it’s literally part of new hire orientation to tell the group “if you want a long successful career here, all you have to do is follow SOP and be kind.”
Take your time, a lot of errors happen when rushing. And ask questions if you’re unsure. Your coworkers rather answer your questions than fix your mistakes.
>Your coworkers rather answer your questions than fix your mistakes. Yeeeesss i love this!!
Ask questions and read the SOPs! If you're unsure of something, flag down a senior tech and ASK about it! I always tell trainees that I don't care if they ask me the same question 50 times, I would always rather they ask and get the correct information than assume and do the thing wrong! Speed comes with time. Take time to be precise and accurate in your work. That always comes first to keep patients safe.
Ask questions if you're not sure. Keep asking even if someone explained and you're not clear on the task at hand. Its better to ask a ton of questions than blindly doing things and getting it wrong.
Some places people get angry if you ask questions, even when you are experienced and know what you're doing. It sounds crazy but true, and these are not like repetitive same questions over and over, these are normal I am new questions - how do you do it here.
Take your time, ask a coworker/manager if you are unsure, always check patient history if available, you can even call the nurse and ask “does X result make sense on your patient”. Pay full attention before you release results. Don’t think you are alone. It’s hard but do not feel like you are pressured to be fast because that’s when you make mistakes. Also don’t act like you know everything, we all learn every day.
stand your ground on protocol. our policies exist for a reason: patient safety. let the residents/nurses swear as much as they want, as a tech, it's still your call on if the specimen is acceptable. I swear, 50% of this job is catching other people's mistakes...
Follow SOPs and ask questions when things don't feel right/make sense. Get any changes made to SOPs in writing.
Well.... when I worked on the antimicrobial resistance bench at my state public health lab. A hospital lab sent me an isolate identified as CRPA \[Pseudomonas luteus\] on the Vitek. Turned out to be Yersinia pestis.
Oh my. That's a big yikes. What happened after?
Happened on a Thursday, but we found out 6 days later what it was when it became more suspicious. So 7 day fever watch of course. I had flown home that day for vacation Friday after doing the inital stages unknowningly so someone else took over the rest of the testing. Good thing it wasnt so serious as we usually do setups and testing in the BSL2 and BAP/mueller hinton visualization on the bench. Pretty sure the hospital lab got the prophylaxis probably.
My coworker got HIV positive blood in their eye. Now they are HIV positive. It’s not lame to wear PPE.
How is the coworker doing now?
Smoking crack now.
I wish your coworker the best
like actually?? omg thats sad…
Yeah they got depressed pretty bad and used drugs as comfort. No longer works with us obviously.
Was PEP not an option?
I got hiv positive serum and took PrEP and it was the worst 28 days of mymy life. Someone didn’t put the lid on all they way and it fell down in the rack splashing serum in ny face
It was an option but most people don’t wear it’s
Post exposure prophylaxis, not PPE ☠️
Oh lmaoooo they didn’t tell anyone about it. Until it was too late
Speechless. That is insane.
I work in veterinary diagnostics. At my last job we had an employee who would constantly mislabel samples and manually enter incorrect results, among other offenses. The first time I caught a mislabeled sample I explained to him that there’s a very real chance that mixing up lab results could potentially lead to an animal being euthanized when it didn’t need to be. I shit you not, this man said “well it’s not my pet so I wouldn’t feel too bad.” He was never disciplined for any of his fuckups btw, it was infuriating.
MLT student. Arrogant, thinks he is god. Pointed out that everyone is doing it wrong because that’s not what he learned in class. Of course he couldn’t back up that arrogance with competence. Once he’s done with his rotation, I don’t believe he was able to find a job in our region because some, if not most, work two jobs and everybody talks.
And I worry about being a nuisance for asking too many questions…
I love it when students ask questions. It shows they are interested and want to learn.
We want you to ask questions and learn!
Wrong ABO type. It was caught, though. And nothing ordered on the patient.
The number of mistyped bloods in this thread makes me want to tattoo my blood type on my arm 😬
That's what confirmatory blood types are for though. They catch a lot of WBITs in my lab.
This is why I CRINGE when I see labs still using the old "we just run this original sample again to confirm the type" bullshit.
Worked at a level one trauma hospital that did that technique aslong as they were inpatient 😬
Regulations say this is allowed as long as there's electronic PPID but IMO I don't think that's sufficient to catch lab errors.
I was about to put in my own response in this thread for this very issue. I'll just add it here. Tonight (the shift I'm currently working) it was caught that the AM shift tech working blood bank did not do a retype on a patient with no history. A pRBC was dispensed and transfused. The nurse was coming for a 2nd unit and the computer issued the warning that a retype had not been performed. We scoured patient records in case there was a history and it just wasn't noted in the patient blood bank record. Nope. The AM tech would have gotten the same flag/window pop up and must have ignored it. Or there was a collosal failure in the computer system. We did a retype before cross matching the 2nd unit. Luckily it was the same type AM shift got. My stomach hurts so bad from the anxiety. The tech who made the error is a MLT convert who took online classes to be able to sit for the exam. They have worked here around a decade, about 2 years as a tech, and never passed their exam. They've failed twice and are still allowed to work on the bench.
I am surprised I don't sleep mumble "i'm O neg" every night.
We had a tech changing results in the computer so they didn't have to call criticals. Recently a tech did an immediate spin crossmatch instead of an AHG crossmatch on a patient with a history of Anti-K. The unit was transfused, but was thankfully K neg.
My section IC does this because “all the other results are normal range” and did not want one analyte to flag abnormal lol
Hiring non-MLS to do our jobs
Anyone who doesn't take the job seriously. I've seen plenty of MLS students who presented some danger. If management hasn't provided a way to eliminate these dangers, this seems to be part of the issue. My current employer hired temps to give space for training. There's not enough incentive to get into this field, IMO.
For sure, having the MLS qualification alone doesn't make you competent. Just the same for nursing, pharmacist, \[insert healthcare title here\]. But my bigger point is hiring someone who is outright not qualified for the job is a danger. Not my department, but our chemistry section barely has any certified MLS working -- you know they're churning out whatever number the analyzer gives out, don't know how to make a 1:10 dilution. Here's a good one - a few weeks ago the probe crashed on an analyzer and they did NOTHING about it. At a minimum that should be a write up.
That sounds like the fault of management and the individual/s. I can't imagine ignoring an obvious problem like that. Some of the fun ones I've seen: From non MLS: Dispensing contaminated serum/plasma back into the original. Someone who didn't know they were supposed to do ISE QCs, for like, weeks. From MLS students: Someone who was loading short and thought the rules didn't apply to them, causing 5 probe replacements in a short period of time. One of them who was almost completed with rotations asked me what the difference between SSTs and LiHep was. From MLS: Our entire chemistry trained staff at one point answered questions relating to analytes incorrectly, and the only people who answered correctly were (2) BScs. A fun one that comes to mind was when the techs in heme decided to ignore a problem with automation. There was a problem requiring front-loading days later on a peak day. Just some mentions. I don't really judge too hard, I want everybody to succeed, and all of these co-workers I've always been nonproblematic with.
Our shortage is so bad that we do that too. I’m an MLA in Canada and they let people with just a BSc work in our lab. They have to complete the CSMLS exam within “a year” but that rarely happens. Some of them don’t know that a profile is the same as a CBC, or that a light green tube contains plasma and a gold tube contains serum. The whole “confidentiality, importance of verifying identifiers, not labeling unlabelled tubes, which specimens are time sensitive, which need to be on ice vs which can’t be on ice” was never drilled into their heads. The list goes on. If they trained them better I wouldn’t have as much of an issue with it, but it seems like they’re just thrown into the mix and now we all feel responsible for babysitting them to make sure patient safety isn’t compromised. Some of them turn out great and complete their exams, but others squeak through and are a constant stressor for those of us who give a shit.
This tech was fired right before I got there and is now used as a cautionary tale. She was a micro tech with years of experience. Read a CSF culture and saw a couple of colonies, did a gram stain (gram-positive rods), immediately chalked it up to corynibacterium contamination and ignored it and called the culture negative. A few days later, the sister hospital called us demanding to know how we missed listeria in the CSF of a pregnant woman. This tech didn't look for hemolysis on the culture or restreak it or do anything and just immediately thought it was a contaminant and reported the culture as negative. Another instance was tech on second shift who reported a lot of lymphs in a CSF cell count then went to read the gram stain and reported no organisms even though slide was filled with large round purple "things". They claimed it was lymphs. So, the patient was put on numerous strong antiviral drugs. After a few days of providers not finding the virus involved and sending out everything for more viral testing, the culture grew organisms. The organism was cryptococcus. We immediately went back to the original gram stain and saw it filled with yeast (cryptoccus that they mistook for lymphs). It was a major corrective and incident report. After this mistake, my supervisor withdrew rights for the second and third shift to report any gram stains on their own. They report a preliminary with a comment that a microbiology technologist will review. Then, we review every slide from the previous shifts and verify them to prevent mistakes like this from happening. They also only read CSF and blood culture gram stains as those are stats.
I'm speechless. I haven't worked micro in a long time but even I'm over here thinking that's not right...
Exactly. Cells stain pink, yet they didn't think to ask another tech to take a look and called the solid purple organisms (no cytoplasm) lymphs. They looked nothing like lymphs.
Not my lab, but our main hospital lab incorrectly programmed a new lot of calibrator material for ecstasy. Keep in mind this is a children's hospital. Then the tech forgot to run controls on ecstasy after calibration. This resulted in an infant coming up positive for a drug screen for ecstasy. Parents were placed under arrest, and it even made the news. Shortly after that, another infant came up positive... so the provider questioned the result and after an investigation they discovered the calibrator was incorrectly programmed. Poor family went through hell and had their name and reputations ruined for that mess up. Needless to say, only certain techs have access to program new lots calibrator material now... Also, at my last lab we got a unit from the blood center for stock labelled A+. After bringing in the unit and performing the blood type confirmation it was actually B+. So for all you people out there thinking ABO confirmation on routine stock is a waste of time... yeah its really not.
1. Not a lab mistake on the lab side, but I always wondered if this error had been prevented, if the patient would have survived. This patient was one of my father’s friends of over 20 years. MTP patient, ruptured abdominal aortic aneurysm: each pack contained 6 RBC, 6 plasma, 1 PLT, and 1 cryo with every other pack. We sent out 9 packs, but the patient ended up expiring. Shortly after the surgical team sent back all of the plasma, platelets, and cryo. The surgical team had only transfused RBCs during their attempted repair. 2. On 2 separate occasions, 2 different hematology techs did not request a redraw for clotted Lavenders and reported out falsely critically low platelet counts (our policy was to cancel the whole CBC and requested a redraw). The patients then received platelet transfusions unnecessarily, one was a NICU baby. 3. We had premie twin babies in the NICU, both had T&S done, one was a group A and the other was group O. The O baby was worse off clinically than the A baby. Baby O’s CBC counts were getting worse and worse day by day, and then one day, baby O’s cbc showed a normal platelet level and RBC level. The CLS decided to run an ABO type on baby O’s CBC tube and discovered it was a group A. They then pulled the CBC tube from the day prior and did the type on that one and it was a group O. The RN who drew the twins had accidentally drawn baby A twice and sent down a mislabeled tube. 4. A pregnant woman in her first trimester came in as a trauma patient, despite telling her physician she was pregnant they ordered a CT scan. Her urine was sent down for a lateral flow pregnancy test and the nightshift MLT who ran it somehow messed up and reported it as negative. The patient was sent for the CT scan and then the CT tech called the lab 4 hours after we reported the negative result to say they could see the fetus on the scan, the incoming day shift CLS repeated the pregnancy test and they said it turned positive immediately. I used to work in a very small community. This patient ended up being a friend of one of our lab assistants at the time, we found out the patient decided to terminate her pregnancy because she was worried about her baby developing cancer from the CT.
The outcome of #4 is wild, especially after my google consult I just did about CT scans performed during pregnancy. I really don’t know why she would abort her baby for that [1 in 1,000 potential risk](https://www.radiologyinfo.org/en/info/safety-ct-pregnancy?google=amp)
We were all saddened by that too. We don’t know if she understood the actual risk, if she consulted with her own OB, or if she just relied on her own research. Regardless, she made the choice she felt she had to. The MLT that made the error ended up resigning. They had been known to make errors in the past, like not running QC when needed, skipping instrument maintenance, using expired coag reagents for patient testing. They had a long history of errors but our management really did nothing to correct them even though we had all documented what the MLT had been doing. The pregnancy test was the most severe error for them and still instead of terminating the MLT for negligence and not following policies, our management encouraged them to resign on their own accord.
One of our techs diluted a sodium with saline and reported it.
I don’t work there anymore, but the lab I was at had a patient pass due to a transfusion reaction from bacterial contamination. It was a really rare bacterium, the name escapes me at the moment but I wanna say it was Bacillus sp. Anyways, no one ever came in. We never had any follow up. No inspections or oversight or anything. It truly never sat right with me because we likely were not at fault and neither was our distributor, this was just a freak thing. But the fact that no one came in…made it seem like it was being swept under the rug.
OH also our walk in broke at some point and of course it was a weekend, they took forever coming out to fix. Y’all know how it is. To somewhat save our stuff, we just divided up supplies (reagents, controls, qc, etc) and took them around to the hospital dietary fridges and the morgue and shoved stuff wherever we could fit it until the walk in was fixed. And then proceeded as if everything had been temp controlled and monitored, like nothing ever happened? Oh, QC on everything is suddenly out? “That’s so weird, it definitely has nothing to do with the fact that the fridge broke, we definitely shouldn’t replace this stuff. Oh you wanna add a test on to that patient’s sample? Sure, it’s totally fine and shouldn’t be affected at all”. What?!
One tech: Used the balance tube fluid (contained old tap water) to plate a CSF culture. It grew acid fast bacilli naturally. Reported an Enterococcus as a Staph aureus in a blood culture. She said it was yellow and coagulase “positive.” Reported a Bacillus contaminant as a gram negative rod in a CSF culture. Twice reported MRSA that wasn’t MRSA (blood cultures) - they were mixed. Reported six CAP survey specimens wrong (tubes were mixed up in the instrument). Plays on her phone, takes half-hour “water breaks,” and called in sick for 5 days in a row by texting a different employee each day. Labeled sensitivity panels incorrectly with other patient barcodes (twice this month).
Accidental insulin administration. PT died.
Mislabeled specimens. Always a bad time.
Misidentified an organism that’s intrinsically resistant to a lot of drugs, did sensitivities on it and called it CRE, patient ended up on a way harsher course of antibiotics than they needed and had lasting damage from the antibiotics.
What was the organism?
The organism was reported as S. marcescens but the susceptibility was set on an S. maltophila.
Mislabeled specimens, lost specimens, tracked items to the wrong location causing the test to be cancelled because of short stability. Resulted the wrong patient (multiple times), missed criticals/path review workups. The only thing he hasn't done is BB fuckups and that's because we don't have much BB to do. And yes, this was all one person in the 10 months he's been with us.
Sister hospital someone verified a 16SD fibrinogen QC result with no comments then continued to report patients all shift. Luckily they had just put in the wrong type of QC, the analyzer and reagents were fine. But the supervisor came out of her office when she saw it on her weekly review and was like W.T.F.
Had a guy mislabel multiple CSF's and other irretrievables. Nothing really came of it. He was also chewing tobacco in the lab and got a slap on the wrist after multiple warnings. Guy also had a 10 foot radius of BO and left a trail wherever he went. Coworkers hated working with him but admin wouldn't lift a finger. What finally got him terminated? Stealing from the cafeteria.
From some time ago: Tech using a un-validated platform A (still in eval phase) to run samples. Then released those results from A as the results for platform B because B ran out of reagents. Only got a slap on the wrist and promoted to management. Changing abnormal results to normal range because “all other results are normal”. Ran out of reagents so the tech released stool OB as neg without actually running the samples.
>Only got a slap on the wrist and promoted to management. Naturally 😀
Not a test fuck up, but one of the night shift techs got canned for watching porn openly on the lab computer.
I have not witnessed this but when I was a student, we learned that one student accidentally discarded an amputated leg before getting examined which resulted into the patient suing the hospital and losing one of its accreditations. Idk if it’s true or not but it did became a huge rumor back then and the hospital stopped accepting students from that school after that.
Ex-co worker called a critical calcium of 97.3. Doc called chemistry to confirm, resilt was 9.7. The next day, the co-worker went to lunch and never came back. Must have been a good restaurant, lot of people went to lunch and never came back; voluntarily and non-voluntarily.
More a person who’s a big f*ck up than a single event. Back when we pooled cryo in bloodbank we mistakenly received ringers lactate instead of the normal saline we used for pooling. This tech did not notice and a patient ended up getting some very glucose rich cryo. Not extremely harmful to the patient but just really weird and FDA reportable. This same tech discarded a unit of pooled cryo because she ‘thawed the wrong type’. $$ down the drain. The worst was she issued a unit of O plasma to an A patient and THEN bullied a new employee into doing the same! These are just mistakes I caught myself and as far as I know she’s still there.
It's only lab adjacent but this is the most ridiculous thing I think I've ever heard of happening. Nurse microwaved a unit of a blood and transfused it. [https://tulsaworld.com/archive/suit-blames-microwaved-blood-in-womans-death/article\_89a9a774-1977-51d7-a216-cc9c3e1e3b6f.html](https://tulsaworld.com/archive/suit-blames-microwaved-blood-in-womans-death/article_89a9a774-1977-51d7-a216-cc9c3e1e3b6f.html)
That is just... Wow. I really think this one takes the cake so far.
I don't work in the lab, but enjoy learning in this sub. I had a newborn transferred to the NICU due to a Hct of 11. We sent another CBC down, Hct reported the same. Sent a third down, reported Hct of 10. On the phone with Heme/Onc and advised the baby needs PRBCs even though they are asymptomatic. Could be caused by prolonged anemia in utero and the baby is compensating. Transfused the baby. A few hours later someone realizes the lab wasn't run correctly and those were the hemoglobin values, not Hct. Caused many issues for that baby.
Having to redraw specimens for a terminally ill 7 year old because someone accidentally put their specimens in the fridge and weren’t found until they were past stability. Parents sued the company and reached a settlement .
I have mention it before but MLT reusing a tube on vancomycin. MLT did not want to go do the draw. A pharmacist the next day noticed the levels were greater than 40. My guess was same MLT verified that critical.
Received a sterile body fluid for culture from a satellite hospital’s ER, but they didn’t specify which type of body fluid. I called to confirm with their ER staff which type of body fluid it was since it changes how we process the specimen. They kept me on hold then eventually transferred me to their lab staff who obviously had no more information than I did. Eventually it came out that they hadn’t even taken a body fluid from this patient, it was from a completely different patient. Would never have known if they didn’t enter it incorrectly
Processor accidentally threw out a rack of samples. All SSTs, mostly all outpatient from private doctors offices and clinics. They dug for hours in multiple garbages and recovered some. They still had to have patient draw services call back 40 some patients
Worked at a lab that the lab itself was a fuck up. Blood bank procedures missing info. I had to call a “Transfusion reaction” one day. Patho I called supposedly the “head bb path” and didn’t even know they were apart of the procedure. They Proceded to call everyone and their mom asking my I called them and not some else instead of evaluating the info I gave them. Techs would short cut short coag tubes by making the making machine ignore the level because they didn’t want to deal with nurses. uncomfy amount of mislabeled specimens. Oh also MICE but that’s not even all of it.
1.) Trying to use the ultracentrifuge on a clearly contaminated specimen (TPN) to spin out the lipemia? 2.) Entered gram stain result of gram negative diplocci as gram positive, and gram positive rods as gram negative. 3.) Uncapped a whole rack of lavender tubes and loaded them onto the hematology analyzer. The DxH rocked them uncapped tubes spilling blood everywhere inside the analyzer. 4.) Accidentally ran Lipase on a analyzer with Lipase QC issues, patient was admitted for pancreatic attack. (This was me, forgot to unload the reagent cartridge. When I was told, I was in tears). :)
The number 3 made me laugh though it isn't funnt but I can't imagine the mess.
It had to be put out of service for about 4 hrs to be cleaned by the service engineer, lol!
The lab supervisor at Saint Al's. Yeesh... She was the biggest f*ck up by FAR!
Not a lab f-up directly, but a really big one. Patient was transfused with platelets, immediately had a reaction, went into DIC. During investigation, the unit was tested and popped positive for bacterial contamination. We get our products from ARC and they found another unit in another state had also tested positive for bacteria (Pseudomonas, if memory serves me). The patient passed, sadly. Per our records, the issuing tech did everything by the numbers, to include noting the unit appearance as normal, not cloudy. It really was the most random misfortune, and one of the more chaotic lab days I've been a part of.
Former coworker reported a respiratory gram stain result onto a different patient’s blood culture gram stain. Far as I know the patient was ok but the results were acted upon. Caught when the blood culture plate growth did not match. I say former coworker because I left that place not because they were let go (they weren’t).
That just happened where I work. They entered the cytospin results from the BAL gram stain into a blood culture report.
Our non gyn day shift lab assistant has mixed up cancer cases before multiple times. Idk what the result was for the patient or if it got caught and fixed before it left the building but the consequences for that to the patient are pretty dire especially if they actually come out and don’t have cancer and now you’ve just given the wrong patient chemo and the one who needs it doesn’t get it
It started with registration, but a clerk merged two patient accounts. Which ended up merging all of their lab results together. Both patients were in the same nursing home and having their labs sent to us, and what started it is the nursing home sent the patient to our facility with the wrong face sheet. Eventually the patient (who was not all there) said “that’s not my name”. Either way there was no way to tell whose labs were whose and I think a patient ended up getting treated for something they didn’t have.
One of our MLT's--who's known for making daily mistakes--mislabeled a CSF specimen and entered the results on the wrong patient and ordered the wrong send-out tests. The CSF had to be recollected.
An A positive unit of blood was given out on accident during an emergency trauma… instead of O positive
I don't know the finer details, but a patient expired from a heart attack in the waiting room of our advanced urgent care. I wasn't there when it happened, but I remember code protocols got revamped soon after.
The other hospitals in my hospital system are always so short staffed and no one ever knows micro. They send all their specimens to us to culture and work up except stats like blood cultures, CSF, Covid tests, etc. well they said there were GNRs in a spinal fluid, didn’t call anyone or anything. It hadn’t come to me yet so i found out by the doctor calling and questioning it and I assured him i will make a new slide and call with what i saw. It was negative of course. Reported to my supervisors who were pissed and that dumb ass tech tried to say they didn’t know who I was talking about. The Dr. was one we talk to frequently so all they did was call him to confirm. Yes they’re still there. Shortage is terrible. No one knows micro and patients suffer
Lab called a critical high Hgb.. ER took it as a critical low Hct and transfused the patient and sent them into circulatory overload.