1 A hospital has recently switched from centralized to decentralized phlebotomy collections. Now instead of six phlebotomists collecting samples in the hospital, over 150 nurses are doing collections.
Different tests require different specimen tubes, and the wrong tube can alter the test results.
A new, untrained nurse for Mary Pickford, an elderly diabetic patient, collects Mary's blood into the wrong tube. This error is not caught in the lab and leads to an incorrect diagnosis and treatment protocol. Example 2 A young boy, Jim Smith, undergoes kidney transplant surgery and requires a blood transfusion. Jim dies during surgery because the process lacked the necessary checks and balances to ensure positive patient identification. Click to see the many root causes of adverse specimen events.