Wrong Slides and Delays

         A while ago, a hospital in the network sent my department some blood parasite slides along with the patient blood sample. We noticed something was off.

         Those didn't look like thin smears for blood parasites. They looked more like standard gram stains. Instead, these were supposed to be thick smears but were prepared wrong.

         Thick smears are supposed to be like the slide in the middle of the chart. We could have remade the slides from the patient sample. Except, there was one problem. The blood sample was too old.

         The sending site waited for days before sending us the slides and blood sample. The sample collection time is crucial for this type of smear because the visibility of blood parasites is only possible at certain times of their life cycle. We had to cancel the test after contacting the medical director. Only under his approval could we credit the test and order a redraw.

         Several days later, we received a complaint from the sending site for canceling the order. This event escalated to the medical director, who had to clarify the protocol written in the SOPs. The sending site later sent fresh slides and samples stat to be run.

         In the end, it delayed patient results. I never found out what happened to the patient, but this was a less-than-ideal situation. The moral of the story is to be familiar with your SOPs. The finger-pointing will not serve the patient's well-being or your ego.

Posted with STEMGeeks



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Thank you for magnifying an issue which is unfortunately common, even if it's not related specifically to improper slide preparation. Delays and lack of accountability are significant issues which negatively impact patient care on a daily basis. Too many people in this industry care more about protecting their backside than actually working towards patient care, and the rules that were originally set out to help patients wind up making the healthcare process far worse.

Thanks for highlighting this, and I hope that you continue to show the care that you've demonstrated here by writing about this situation. 😊

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Yeah, it's more common than we think, unfortunately.

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It's always someone else's fault. That is the world we live in these days. I get that quite a bit. Calls or emails asking where we are at with something. Did you send me the information I needed? No? Well then we aren't done.

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In this case, there seems to be unfamiliarity with protocol and not following up in a timely manner.

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wow ! that is a total mess.. mistakes happen, at least in the research side , I have already seen things worst than that, but when you have a diagnosis associated to a good test it is so depressing for the patient side.
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It's a learning experience. Not a pleasant one.

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