Causal Tree - Case Study

Causal Tree – Case Study

A night technologist was testing two patient samples for ABO and Rh. The first patient, Ms. Smith, typed as an A Positive. The second patient typed as an O Positive. The technologist entered the results onto the worksheet. Then, using the worksheet, she entered the results into the laboratory information system (LIS). Unlike the other shifts, she did not have another technologist to do second checks of her results. The first patient was entered and the result was accepted. However, when the technologist entered the second patient, a warning flashed up on the computer screen that said the current type did not match the historical type.

The technologist double checked her work and found that the tests themselves were done correctly and the tubes had not been switched but that she had reversed the results when entering them on the worksheet. She corrected the worksheet and notified the supervisor at shift change to get the test results for the first patient changed in the LIS.

The technologist felt terrible about what had happened. It was normal to test more than one patient at a time. She had never had any trouble in her six years of experience. However, she had been coming in to work the past three days despite being ill. In retrospect, she decided she should have called in sick even though the supervisor would have had to come in.

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