Introduction
In true Hollywood style we must start by make this declaration ….
“This is true account of an incident with an MSoft360 team member in an NHS Hospital Emergency Department in 2019 and has been anonymised.”
Let’s call this team member Steve Austin. Yes, we know this is the 6 Million Dollar Man and he should not be here but let’s go with the flow. His date of birth is also the first episode air date of 24 October 1974.
This story is about Steve Austin arriving at the Emergency Department complaining of chest pain and feeling dizzy.
The following account is his troubled journey through the Emergency Department in the NHS Hospital.
The result of this unfortunate journey was a set of important STAT Blood Samples simply left in the Emergency Department for 90 minutes and never sent to the Lab with the Lab being none the wiser of their existence.
Background
Things will go wrong in Hospitals because at the end of the day we are all human and external factors will affect our concentration whilst we carry out our task in hand.
Sometimes these errors will result in a stubbed toe or in the worst-case scenario could even result in death or serious injury in a car incident.
But when things go wrong in a Hospital it could have a disastrous outcome.
Let’s start by pointing out that just like the book “Black Box Thinking, by Matthew Syed” we must look to Failure as a learning process and not a blame process. This account attempts to show how using Sample360.cloud we can learn from these unfortunate events and make sure it never happens again.
Summary
The Five Failures during this process were caused by human error in a busy Emergency Department. The solution to these Failures would simply be Sample360.cloud.
The main Four Green errors are incorrectly interrogating the Patient for their correct ID due to leading questions and no wristband. This generally causes wrong blood in tube errors (WBiT) and these errors can be as high as 20% in the Emergency Department.
The Two Amber Failures are due to minor process Failures with excess Labels not being destroyed after use and wristbands being used to identify sticker sheets and not the Patient.
The Four Red Failures are more serious process Failures that result in a more serious risk to the Patient such as:
- Pre-printed Labels potentially resulting in mislabelled tubes with the incorrect bleed time.
- Re-Labelling of the Sample tubes in the Lab which not only waste time but introduces another point of Failure.
- The Lab being unaware of the LOST Samples which could have resulted in serious harm to the Patient. This is because they were unaware the Bleed had taken place.
- Samples never made it to the Lab and no member of the team knew about it.
The Solution to all these Failures is Sample360.cloud as it is a Closed Loop Sample Management system that records who, what, where and when a Sample is taken which means 100% traceability is achieved with 0% lost and rejected Samples.
To find out more please read the following white paper:
Sample360 – An Unfortunate Series of Events in the Emergency Department
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