For those of you who may still think that the lab is responsible for most of healthcare mistakes, this thread is for you:

Back when I was working in the core laboratory, I was working one night in chemistry. We had 2 MLTs & 1 MLA on night shift. The other MLT was in heme/TM.

While my MLT colleague was on break, I took over heme/TM for them, running & resulting their samples. I received one type & screen, checked it for hemolysis, and loaded it on our Ortho Vision analyzer to perform the testing. I went back to chemistry to finish up some testing/QC.

Half an hour passes and I check to see if the results for the type and screen have come out yet. I open the Meditech analyzer batch and see an error code next to the sample. I go into the sample result to investigate.

A pop up message comes up saying that the blood group does not match the historical group. I review the patient's history, and do notice that they have two previous type & screen samples with the same blood group, one of these samples having been collected 1.5 hours earlier.

I reviewed the collector information from the earlier sample that night and saw the mneumonics of the MLA in emerge (who used to work in the core lab, which is how I knew their mneumonics). The sample that was recently received was from an agency nurse, not a hospital employee.

I called emerge & spoke to the charge nurse to tell them of the mistake. I told them that if they needed blood on this patient, we could do the crossmatch on the previous sample. She said thank you, and that she would talk to the agency nurse and figure out what happened.

I cancelled the type & screen and submitted an incident report on the agency nurse.

It is not unusual for laboratory staff to be catching pre-analytical errors similar to this one. I have attached a table from Hammerling (2012) that further illustrates this.

So next time you blame the lab for a mistake or complain about having to redraw a sample, remember that our job is to ensure that accurate and reliable results are reported on patients, as incorrect results could lead to improper diagnosis & treatment of patients, even death.