Blood was requested by me a day before but was not transfused because patient has no good peripheral line. After a central line was created and hemoglobin was still low, another order to transfuse 1 unit Packed Red Blood Cells was written by the doctor. Since 1 unit of PRBC was readily available for the patient, I informed the blood bank if I could take the unit that morning and was told to have it. The blood bank staff took the unit out from their big refrigerator, pasted the name of my patient on the blood bag, and in turn, had me checked the blood type, the serial number and the expiry date that matched the compatibility and the request form. I signed the request form without checking the name on the right upper part of the form. Blood bag was counterchecked and signed by the resident doctor. Since the name , hospital number and blood type handwritten and pasted on blood bag was the same with my patients', I was then certain that everything was perfect. Transfused the blood at 6:20am, endorsed at 7 o'clock and went home and slept in preparation for another night shift.
Back at work, blood bank called 6 hours after I left, asking if blood requested the previous morning is still needed. Staff assigned to my patient informed them that blood was already transfused! Blood bank panicked, came to ICU and checked on the patient and the papers that were sent together with the blood bag. The request form given to me was for another patient which was wrongfully given by the blood bank staff, which I and the ICU doctor didn't recheck. Doctors and ICU heads were contacted and verbal report was given with the instruction of the blood bank director wanting to "talk to the staff who transfused the blood".
I was informed that night what happened. Everybody was on the height of their emotions while I stayed calm knowing that nothing happened to my patient. I waited for our department head the next morning but she didn't say a word when she saw me. Thought that everything was okay, I went home excited for a double days off. At 10am, when I was about to take a good slumber came telephone calls telling me to go back to submit an incident report. An Incident Report or an OVR (Occurrence Variance Report) is a protocol wanting to know the 'why' and not the 'who' of anything that had happened that needs reporting. I wrote the IR the next day, submitted it to the ICU team leader and heard nothing more until the next night I came for duty. TRENDING was the only word I can use to describe how my fellow nurses have reacted on the incident. While I was enjoying my 2 days off, everybody in my department have had different stories, made opinions of their own, some mistakenly thought I was re-oriented by the department because I wasn't coming for duty, some were asking if I am okay (which absolutely I was!), some looked at me as if I've killed a patient, few were simply staring at me as if wanting to know my reaction. A colleague, a charge nurse praised me for submitting a well worded Incident Report, which was written in full truth and having me accepted humbly my fault and didn't blame anyone for my mistake. Yet, no matter how everybody thought of the incident, what matters most was NOTHING happened to my patient! Some said I was lucky that same blood type was transfused. Indeed, it was fortunate of me having given same blood type but the incident left me something to think about - that no matter how effective and efficient and well experienced you think you are, incidents like this could happen, incidents that would serve a lesson or two, incidents that made me more careful with my decisions and more importantly, the incident made me realize to take good care more of LIFE.
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