Patient-labelling error led to unnecessary blood transfusion

PUBLISHED : Saturday, 27 September, 2008, 12:00am
UPDATED : Saturday, 27 September, 2008, 12:00am

A patient received an unnecessary blood transfusion after a nurse clicked on the wrong patient name when generating specimen labels.

The Hospital Authority detailed the blunder in its latest Risk Alert report released yesterday.

The nurse had been generating specimen labels before taking a blood sample from a patient when she was called to attend a second patient, the authority said.

When she resumed the process of generating labels, the nurse instead clicked on the name of the second patient. The nurse took the labels to the first patient for blood-taking.

When the results came through, an on-call doctor prescribed a transfusion because the result showed a drop in haemoglobin, a protein in red blood cells.

The case doctor detected the discrepancy in haemoglobin levels and asked for an investigation. The patient recovered.

The authority said there was a failure to check the correct patient was selected when generating labels, and to check the identity on the label.

Hospital staff have been advised to exercise care and strictly adhere to the checking process for patient identification and correct labelling for blood sampling.

In another incident reported in Risk Alert, a patient was fitted with the wrong plastic lens for treating cataracts, intended for another patient.

The operation on the first patient was rescheduled after the patient complained of dizziness and abdominal pain. When the second patient was sent to the operating room instead, the special lens intended for the first patient was inadvertently used. It was found that before the implant, the surgeon had been distracted by a phone consultation, which also contributed to the mistake.

A nurse discovered the mistake and an immediate exchange of the lens was arranged for the second patient, who only needed a commonly used plastic lens.

Staff were advised to ensure they check the patient against the identifiers on the prescription and the lens.