Volume 180 - Issue 4
Occupational exposure to HIV: response to a system failure
Authors: Elizabeth E Cooper and Stephen L Blamey
Med J Aust 2004; 180 (4): 195. || doi: 10.5694/j.1326-5377.2004.tb05868.x
Published online: 16 February 2004
Published online: 16 February 2004
Elizabeth E Cooper,* Stephen L Blamey†
* Sterilisation and Infection Control Coordinator, Southern Health Infection Control and Epidemiology, Southern Health, Locked Bag 29, Clayton, VIC 3168; † Head, Department of GastrointestinaI Surgery, Monash Medical Centre, Melbourne, VIC. elizabeth.cooperATsouthernhealth.org.au
In reply: Emmett and colleagues request more information and analysis about the mistaken use of stored serum samples.
The pathology staff member correctly labelled the specimen of the patient being bled but did not follow the protocol in identifying that the patient was the same as on the request slip. It had not been highlighted that there were two patients with the same surname (but different first names) in the ward, and blood was collected from one patient with a request slip labelled for another. At specimen reception, the protocols were again not followed, as the staff did not check that the minimum identifiers on the specimen label and request form matched.
It is recognised that violations of procedures are not root causes and are not directly manageable. The cause of the procedural violation must be managed.1
The collection and labelling of blood protocols were reviewed after this incident and found to be appropriate. The root-cause analysis identified that the protocols were not followed and that unacceptable “informal norms” had become practice in the collection and labelling of specimens. Staff training was examined and revised to ensure that staff were aware of the content of the protocols and that they followed them accordingly. All staff members were counselled about the importance of following correct procedures and the consequences of not doing so.
Up to 1000 specimens are received at specimen reception each weekday. New “front end processing” technology is to be introduced at the end of 2003. This electronically scans the specimen and request slip to ensure details match.
In the interim, in recognition that mislabelling will occur, all specimens relating to occupational exposures are collected at the time of the incident. Previously available results and serum stored in the laboratory are not relied on.
References
- Bagian J, Lee C, Gosbee J, et al. NCPS triage cards for root cause analysis. Perry Point, Md: US Department of Veterans Affairs National Center for Patient Safety, 2001. DFIEHIDF