Wrong patient transfused: A male patient had his haemoglobin level checked and a low result was phoned back to the clinical area from the laboratory.
However the medical scientist in the laboratory was familiar with this patient's haemoglobin level and noted that the low result was unusual for this patient. The treating doctor was informed. The doctor asked that the haemoglobin test be repeated but in the meantime prescribed two units of red cells for the patient.
By the time the test was repeated, showing this patient did not require blood, one unit of red cells was already being transfused.
On investigation it was established the person who took the blood sample, the phlebotomist, had taken the sample from the wrong patient. The correct identification procedure was not performed as the patient was not asked to identify himself nor was the ID wristband checked. A total of 300ml of red cells had been transfused to the wrong patient.
Fortunately, the report says, this patient happened to be the same blood group as the patient from whom the sample had actually been taken and there were no complications as a result.
Source: National Haemovigilance Office annual report 2005