A Case Of Mistaken Identity Susan Mitchell, FIBMS Chief BMS Blood Transfusion
Importance of Correctly Identifying Samples • Why do you think it is important to ensure that samples are correctly labelled? • Ensure it is the right sample with request • We assume that it is from the correct patient • Correct patient=correct results=appropriate treatment • Every year Blood Sciences receive samples that are ‘wrong blood in tube’ • These are often only detected when deviations from historical records are flagged up • Examples of differences can be: • Different FBC values • Different Chemistry values • Different blood group results
Setting the Scene • Samples and request forms received in Reception for an antenatal patient identified here as AG • All correctly labelled including hospital number AND NHS number • A record existed on Apex for a patient with these details • Booked on under existing record for Fbc & HBEL, Down’s screening and group & antibody screen • Samples were then processed as normal by all areas
What happened next? • So, how did we find out there was a problem? • Writing up batch of blood groups • Computer flagged up that current result did not match historical group • ‘Oh bugger’ moment • Historical group was B RhD Positive, blood in this sample was O RhD Pos • Checked sample was correct & it was the ‘correct sample’ • Start investigating how this had happened and raise a clinical incident
What did the investigation reveal? • There were a number of scenarios: • Wrong patient bled • Illegal immigrant using another identity- it does happen! • Patient had had a non ABO matched BMT-very long shot! • Informed Haematology and Chemistry of problem • Contacted the midwife who had signed the forms and samples • Patient had been bled in her own home as this was the patient’s antenatal booking appointment!!!! • The midwife was to go back to the patient and get a history as our record showed that there was a previous pregnancy
What did the investigation reveal • Patient was at what had been assumed to be a new address • Different obstetric history to the historical record and had recently moved to the area • Two patients with the same name and DOB but different obstetric histories and blood groups and living at different addresses! • AG’s bloods repeated and a new record created. • Number of different departments involved as different IT systems in use • PAS • Euroking (maternity system) • Open Exeter • NHS Records • The patients had been assumed to be the same person on all these systems!!!
Just to complicate things! • Repeat bloods attached to incorrect record in Haem/Chem • Easily sorted • Separate PAS record created but then someone (sigh) merged the records again despite being flagged as not for merging • Back trace started to establish history of NHS number • NHS records office to investigate • Took from August 2010 to February 2011 to finally untangle the two patients • AG due to give birth at end of February!!!
Where are we now? • AG now has her own unique NHS number and hospital number • Separate records once more on PAS , Apex, Euroking etc • AG gave birth in early March • Investigation now closed • There are 10 patients on Apex with the same name and various DOB’s but only two have the same DOB • This is not a rare or unique problem
Lessons Learnt • In the last 6 months 3 sets of patients with the same name and very similar DOB’s have been mistaken for each other • All had different addresses and in two cases had at one point different NHS numbers and hospital numbers • Very important to check these details when booking in to avoid attaching requests to the wrong patient • Particularly with WOE once a electronic pathway is created the error is repeated until that link is broken • Always remember that the results we produce have the potential to influence patient treatment • All three were picked up because of different blood groups-will not always be the case