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At midnight on Saturday a nurse from
the Emergency Department in Hospital B brings to the transfusion service a blood
supplier shipping container with 3 units of crossmatched RBCs. (The
blood supplier also operates a centralized transfusion service and
performs compatibility testing for some of its customers, including
Hospitals A and B.) The
blood arrived
with a patient who had been transferred from an outlying small hospital
(Hospital A).
The supplier container still has an intact tamper-evident seal but no
temperature indicator. All inter-facility transportation in the region is based on
shipping with containers validated to maintain acceptable temperatures at
defined ambient temperatures for specified time periods.
When the sole laboratory technologist on duty phones the
originating hospital, she is told that the
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RBC units had been shipped by the supplier via Greyhound
bus and had just arrived at the hospital when
the patient was about to be transferred.
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As a result the box was not opened on-site and was
given to the air ambulance staff for transport with the patient to the
larger facility.
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The supplier's issue record indicated that the units were
packed 25 hours ago (11 pm Friday).
When the RBC left the supplier, the temperature was 15o
C (59o F) but had soared to 35o C (95o
F) on Saturday.
Transportation from both supplier to Hospital A and from
Hospital A to Hospital B took much longer than expected. The Greyhound bus
suffered an engine breakdown en route and had to be replaced with another
bus. As well, the air
ambulance had experienced a long delay on the runway due to severe
thunderstorms in the area.
The technologist at Hospital B is unsure about whether the blood
is acceptable to use. She remembers that the recommended transport time is
no more than 24 hours but it is only one hour past that and is only a recommended maximum. She does not notice that the shipment has
no temperature monitor and is unaware there are maximum shipping times for
specific ambient temperatures.
The technologist decides to place
the RBCs in inventory for possible transfusion to the patient. On her last two
shifts this month she had had to telephone the on-call supervisor, who had been terse
in her responses and indicated that she did not appreciate being called
over such routine matters.
The patient did not require transfusion overnight and
the next day the supervisor removed the RBCs from inventory. She
placed a report in the technologist's personnel file documenting the
incident and made an appointment to discuss the issue with the
technologist prior to her next shift.
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