casesfromthe2007shotreport(编辑修改稿)

casesfromthe2007shotreport(编辑修改稿)内容摘要：

, and he confirmed that „all the blood can go though this‟. Five units were transfused instead of the intended 2 units. insert your department, conference or presentation title • Excess red cells are administered to an infant despite correct dose calculation and prescription • 171 ml of red cells were transfused over 7 hours to a 3 month old baby with a rhabdomyosara. The child had only been prescribed 80ml over 3 hours, and her Hb consequently rose from to g/dl. The error was partly caused by a failure to include the 71 ml given during the night shift to the volume given during the morning. However the day staff still transfused yet another additional 20 ml for which no rationalization could be made. insert your department, conference or presentation title • Helpful nurses and doctor administer platelets to the wrong patient • Platelets arrived in ITU and sister took them a patient‟s bedside. This was not the bedside of the patient to be administered platelets. However, finding the patient unconscious and without an ID bracelet she went to write a wristband. Two other nurses saw the platelets and checked them by asking other staff if it was the correct patient. Finding the platelets were not written up for that patient, they asked the doctor to prescribe them, which he did. The platelets were then given to this patient who did not require them, but they were for another patient on the unit. There was no adverse reaction. insert your department, conference or presentation title • Confusion regarding ponents results in unwanted red cell transfusion and delayed surgery • A 77 year old man had prophylactic platelets written up prior to spinal depression surgery. Night nurses erroneously collected red cells which were also available for the same patient as they were cross matched for the morning list. Two units of red cells were transfused over 30 minutes each, and no platelets. In the nursing notes the transfusions were documented as platelets, and it seemed that the staff were unfamiliar with the different types of blood ponent. The surgery had to be delayed in the morning when the day staff discovered the error. insert your department, conference or presentation title • Lack of understanding of possible consequences of actions • 2 trained nurses checked a unit of blood at the nurse‟s station and a nurse then walked into a 6 bedded bay and connected it to the wrong patient with no bedside check. The nurse then realised her mistake, disconnected the giving set from the wrong patient and reconnected it directly to the right patient. A senior colleague queries her actions as she had used a fluid giving set, not a blood giving set. The nurse was sent away and the senior nurse changed the giving set as she was unaware of the previous mistake. The rest of the transfusion was then administered (to the right patient). The patient who had received a part unit of wrong blood was not monitored and nothing was documented in the notes. insert your department, conference or presentation title • Size of patient not taken into account when prescribing red cells • An 18 year old male patient weighing 35kg, with a probable TB chest infection, received a 4 unit red cell transfusion based on an Hb result of referred to a medical team and another junior doctor prescribed a further 2 units of red cells making a total of 4 units. Post transfusion the Hb was that the initial sample was taken by a junior doctor in Aamp。 E using a syringe during a difficult cannulation. The red cells settled in the syringe before the sample tubes were filled, giving an inaccurate result. No IV fluids were in progress at the time. No adverse reaction or ill effects were noted from the transfusion. insert your department, conference or presentation title Failure of Check Procedures insert your department, conference or presentation title • Red cell units ‘checked’ at nurses station • An 84 year old male patient was awaiting top up transfusion for anaemia due to prostate cancer. A unit for another patient had also been collected from the issue fridge. Units were checked at the nurse‟s station. A nurse then took one unit and menced the transfusion on one of the patients without performing any bedside checks. This patient who was O D positive thus received a unit of blood intended for another patient which was A D negative. He developed fever, haemoglobinuria, hypotension and loin pain which resolved with full recovery. insert your department, conference or presentation title • Second unit of a routine transfusion administered without checks • A nurse removed a red blood cell unit from a satellite blood fridge without checking the patients ID details or signing the blood register. The 75 year old male patient, group O D positive, was still finishing the first unit of a two unit transfusion for MDS. The nurse left the second unit in the treatment room and subsequently fot that she had not checked the unit against the prescription form or patibility label and put it up without checking the patients ID wristband. At approx 2140 after the blood had been running for 15 minutes the patient developed rigors, pyrexia and the transfusion was stopped. The unit was found to be for a different patient with the same first name. Piriton and hydrocortisone were given, and salbutamol as the patient became wheezy. Haemoglobinuria was observed. The patient made a full recovery. insert your department, conference or presentation title • Red cells administered by doctors in theatre without checking • A 69 year old man was in theatre undergoing emergency repair of an abdominal aortic aneurysm. A junior doctor collected an incorrect unit of group A D positive blood from the theatre fridge. The identity of the unconscious patient, wh。