Rosewood Medical Center
712 Hospital Drive, Omaha, Nebraska 68183
Rosewood Medical Center Notice:
It has recently come to the Rosewood Medical Center’s attention that there was a
blood sample accident that most recently occurred. However, there is no need to panic, as
the situation is currently being handled with the utmost attention and professionalism. \
Because of this recent incident, the hospital board has decided to create a revised set
of instructions for transferring blood samples in order to ensure that everyone understands
their responsibilities to the hospital. These new procedures will hopefully reduce the
chance for accidents to occur and help the hospital run more efficiently also.
The Rosewood Medical Center uses pre-approved procedures to properly handle
blood samples in the laboratory. It is important to follow these procedures correctly to
avoid possible accidents that could occur in the transfer of blood samples to a separate
facility.
Because these samples are taken from delicate patients, a trained laboratory
technician should be responsible for transferring the blood samples. Our patients are in
weak condition and having to take another blood sample from them would be difficult.
The process of transferring should take about two hours. Speed is not as important
as being aware of your surroundings.
It is important to understand how to effectively label the blood samples from the
donors. Special attention should be given to labeling the blood samples correctly. Each
individual donor contributes a very specific set of samples that are widely varying in
content. Thus, one mislabeled sample could cause a chain reaction of harm and
unnecessary hassles for our staff.
The essential tools that are required to use will be a cart with a stopper, sanitizing
equipment, bright lighting, and temperature (no high humidity), as well as typical lab
equipment (i.e. gloves, syringes, proper lab attire, etc.)
If anything occurs that either does not follow protocol or if there is an occurrence of a
hazardous situation, to alert the nearest supervisor and take care of the situation immediately
and efficiently.
Above all else, make sure to follow all instructions carefully and avoid mistakes at all costs.
Any mistake can be detrimental and costly to the hospital.
Rosewood Medical Center
712 Hospital Drive, Omaha, Nebraska 68183
How to Properly Remove/Transfer
Blood Samples
These are a list of specific instructions that should be used to properly remove blood samples and
transfer them to another facility. It is important to follow the proper order and not to ignore any
instructions to ensure the most effective transfer possible.
Instructions:
1. Gather the proper equipment needed for the transfusion of blood samples.
a. Before even beginning the blood sampling process, all employees should
run an inventory on the necessary items needed.
b. Items required to take the blood samples from patients should be
specifically accounted for separately from the equipment used to transfer
blood samples from one clinic to another.
c. Items that must be inventoried: cart with a stopper, sanitizing equipment,
bright lighting, and temperature (no high humidity), as well as typical lab
equipment (i.e. gloves, syringes, proper lab attire, etc.).
2. Properly draw the blood samples from patients
a. When drawing samples from patients, make sure to double check the
donor information is correct and that the samples are labeled correctly.
Rosewood Medical Center
712 Hospital Drive, Omaha, Nebraska 68183
3. Test blood samples, and send a report of the results to the doctor
a. Report should include the donor number, blood type, and other properties
of the blood sample taken
4. Carefully prepare the blood samples onto the rolling carts and prepare to transfer
the materials
a. This stage begins the transferring process. At this point, it is important to
pay special attention and focus on the task at hand.
b. There should be at least two people involved in the transferring at all
times, and at least one person in control of the cart at all times.
5. Take the rolling carts with the blood samples and properly transfer them to the
next facility
6. Remove blood samples from the cart and make sure that everything has been
properly transferred over
a. When removing samples, do not spill and/or tamper with any of the
samples.
7. Put away all equipment and tools. Dispose of anything that cannot be used again.
8. File a report on the transferring of the materials and send it to the proper advisor
a. When filing the report, highlight anything unusual or strange that occurred
during the transfer. This includes any spills or other possible hazardous
scenarios.
Rosewood Medical Center
712 Hospital Drive, Omaha, Nebraska 68183
Date:
To:
cc:
Subject:
February 13, 2008
Shannon Phillips, Laboratory Supervisor
George Jones, CEO Rosewood Medical Center
Last week’s spill of blood samples
I was a little shocked to hear about the situation that recently occurred regarding the blood
samples from our patients at Rosewood. Although it will be difficult to fix what has been done, I
feel as though our team, despite this incident, can figure it out and turn this ship around. The
only problem I see arousing is our timeline for getting the necessary testing completed. Our
original plan was to have the testing started by now. My instinct is leading me towards waiting
up to a week to get new samples from our patients due to the fact that they are in discomfort and
in a small recovery phase from the first drawing of blood. This does however put us a week
behind, approximately, on this project.
Unfortunately, there was a very hazardous situation created from what has happened. Because
these samples contain the possibility of HIV, the exposure of the fluid to our staff members,
including yourself, is a scary thing to think about. While the consequences of this could be
daunting and before conclusions are drawn too prematurely, I think the best bet is to get
everyone that was on the site the day of the spill to come in to the lab for testing. Referring to the
timeline again, this should be able to be accomplished while our patients rest and recover for a
few days. Thinking on a positive note, if all members of our team were wearing the proper safety
apparatuses, as they should have, then we should have nothing to worry about in regards to
contracting HIV from a sample.
Although you were the team leader for this project, we (as upper management) understand that
mistakes happen and this could have happened to anyone. Plus, we see you’ve been doing a great
job as the laboratory supervisor over the past few months and this incident should not take away
from your success. Your leadership abilities are essential to our company’s laboratory success,
which is why we want to make sure you effectively display these skills for days to come. You
are not solely liable for this recent situation; as a whole, we need to do our absolute best to get
back on track within one week or so.
Keep your calendar free within the next week or so as best as you can, as an email will be sent
out to the entire team regarding the fixing of the situation and return to the status quo. Hopefully
you and your team learn from this situation as best as possible because this will be asked of you
again, and we most definitely do not want a repeat of this kind to any degree. Thank you for your
cooperation and I look forward to the resolution phase with you and your team.
Rosewood Medical Center
712 Hospital Drive, Omaha, Nebraska 68183
Shannon Phillips, Laboratory Supervisor
608 Broadway
Normal, Illinois 61761
September 4, 2012
Dr. Alice Keenan, MD, Director of AIDS Center
Apology for Spilled Samples
Rosewood Medical Center
712 Hospital Drive
Omaha, Nebraska 68183
Dear Dr. Alice Keenan:
I would like to extend to you my most sincere apologies for the problems that had happened
regarding the spill of the blood samples that occurred here under my watch. I completely
understand of your frustration towards us for this mistake and I would like to promise you that it
surely will not happen again. I also understand your frustration that now you will have to be
asking your patients for more blood samples, when in reality, they may be weak from their
conditions to be able to give us more blood samples. I also understand of the fear that because of
the spill someone could have possibly contracted the HIV virus and therefore would lead us into
a law suit and I know that that is not what you or anyone here at the company would want to
happen. I know that you question my leadership abilities and I would just like to point out some
of the things that we plan to change so that an unfortunate situation, like the one that happened
here earlier, will not happen again.
One of the first things that I, personally, will make sure of is the transferring of the blood
samples. I will make sure that either I or another highly trained lab technician will see to it that
the blood samples are transferred safely and securely to the facility of which it is to be delivered.
That way both you and I know that the blood samples are being handled and delivered by good
trustworthy people who are trained in these types of situations. My technician who was handling
the cart would also like to apologize sincerely for letting the accident occur. This was the first
mistake that my technician has made while working for me and both my technician and I will
promise that something like that will never happen again.
Another one of the changes that I am having made for future instances is making sure that the
new transferring process goes smoothly and efficiently. Unfortunately, this will then result in the
transfer process going longer than what it previously would take. But in my professional opinion,
I believe that speed is not as important as being aware of your surroundings or making sure that
the blood samples arrive safely and securely to the location of which they going. This will then
ensure that we would not then need more blood samples from people who, because of their
weakened condition, will not be able to donate more blood samples to us.
Rosewood Medical Center
712 Hospital Drive, Omaha, Nebraska 68183
I will also be personally making sure that all of the blood samples are labeled properly. This is
one of the most important things that I will make sure happens here at our facility. The reason for
that is because as you had said in the memo that some of the blood samples that we had been
from patients who had contracted the HIV virus. I understand your anger and frustration with us
because, yes you were correct there could have been a dreadful situation in that if one of my
coworkers had come into contact with one of the contaminated blood samples, then leaving us a
huge liability for a law suit. I know that a mistake like that could not only ruin the company but
ruin some people and their family’s lives, so I promise that a mistake like that will not happen
under my watch here at our facility.
I will also be making sure that every cart used in transferring blood samples has a proper
working stopper at the wheels or at least some sort of locking system. That way if there is an
important reason for either the trained lab technician or I to depart from the cart for a moment or
two, then the cart will not roll even on an incline. I will also be making sure that each cart is
properly supplied with enough sanitizing equipment, enough bright lighting, and is in a location
with proper room temperature with no high humidity for the blood samples.
I will finally then make it an extreme importance to my coworkers and to the rest of the staff that
if anything does not follow protocol, if there is something that turns into a hazardous situation or
anything else that could go wrong to alert the nearest supervisor. I will then make sure that they
take care of the situation immediately and efficiently. I will then warn them of the importance
that they both follow all instructions carefully and to make sure they try to avoid mistakes. But if
need be I will warn them that if a serious mistake should occur because of a lack of following
instructions, they will be dealt with immediately.
Once again Dr. Keenan, I would just like to express my deepest apologies for the mistake that
went on here at our facility. I sincerely hope that these changes that I have shown to you changes
your opinion on my leadership abilities and that you have faith that you can trust us to get the job
done and done right for you. We value your time and trust with us for the near future.
Sincerely,
Shannon Phillips
Laboratory Supervisor
Copyright © 1998 by Ann Poe