My pager sounded its loud, shrill, urgent call, something that always caused my heart to flutter. It was an anxious technician from the pathology laboratory.
“Doctor, you’ve sent us a blood sample on a man called Walter Franklin. The request card says he had surgery yesterday. I thought you ought to know; his haemoglobin is only twenty percent of normal. I’ve checked with the blood bank and they’ve no blood cross matched for him. I think you ought to get a sample down to them straight away.”
I was stunned. I’d seen Mr Franklin not a couple of hours before and he had looked as right as rain. There was no suggestion that he was bleeding. He certainly hadn’t look pale or shocked.
I dashed back to the ward, grabbed a needle and syringe and ran to his bedside. But when I got there he was sitting up in bed, reading the newspaper, looking pink and healthy. His observation charts showed a rock steady pulse and blood pressure. He wanted to know why I was in such a rush!
My brain tried desperately to consider the possibilities. Surely his haemoglobin couldn’t be so low. I wondered if the samples could have got mixed up in some way. Had I labelled some bottles incorrectly; put the wrong name on one of the specimens? If so, another of my patients, unbeknown to me, was quietly exsanguinating! This also seemed unlikely as any patient with a blood count of twenty percent would be extremely ill. I’d seen them all less than two hours ago, and none of them had given me any cause for concern. Could the laboratory have mixed up the samples at their end?
I took a sample for repeat haemoglobin estimation as well as one for cross match and sent them urgently to the lab for further analysis. I rang the technician to tell her that the samples were on their way and asked her to phone me as soon as the result was known. Within 50 minutes she rang me back, sounding much more cheerful this time.
“The haemoglobin’s 95% this time,” she said. “That’s odd isn’t it? So strange, in fact, that I’ve spoken with the boys next door in the biochemistry laboratory to see whether they’ve received a specimen from Mr Franklin this morning.”
“They will have done,” I said, “I sent a specimen for urea and electrolytes as well.”
“Yes, I know – and it seems that the patient has virtually no potassium in his blood and more salt than you would find in the Dead Sea. According to these results, the patient ought to be dead! Can I ask you Doctor, does the patient have a drip up?”
“Yes,” I said.
“And is the drip running a sodium chloride solution?” There was now a humorous edge to the technician’s voice.
Suddenly the penny dropped and I realised exactly what she was saying – and precisely what I’d done wrong. The patient had a drip into his forearm and I’d taken the blood sample from the crook of the elbow, about three inches higher. The initial sample had been a mixture of a little blood and a lot of the salt solution that was being administered.
“Oh my God,” I said. “I’ve taken blood from the drip arm, haven’t I?”
“It looks like it,” she said, “but not to worry – it does happen from time to time, especially at this time of the year when you newly qualified doctors join us. Can I suggest that you take a sample from the other arm, just for the record?”
It was another lesson learned the hard way.
When delivering healthcare, the occasional mistake is inevitable. To err is to be human. The secret is to acknowledge one’s error and learn from it and ensure it is not repeated.
In my experience, factual errors tend not to be repeated.
It is errors of behaviour such as overconfidence or failing to heed advice that lead to recurring mistakes.
Thought for the day
You are thirty two. You are rapidly approaching the age when your body, whether it embarrasses you or not, begins to embarrass other people. – Alan Bennett 1934
Extract from doctor’s letter: Patient has two teenage children but no other abnormalities