Human error causes loss of human blood

Human error causes loss of human blood

Quebec City (Quebec) 3 July 2015 – Because of human error and a fridge that was malfunctioning, the CHU (University hospital centre network) had to throw away about 91 bags of blood last week. The blood was being stored in a fridge, adjusted to a designated temperature where it usually is, until someone noticed that the temperature was above the normal reading. Blood has to be kept at a temperature of between 1 degree C and 6 degrees C in order for the hospitals to be able to keep it as long as possible.

The particular fridge involved in the incident had stopped working a few days before, so the blood was transferred to a second fridge used for such emergencies with no problems. It’s when the blood was returned to the original fridge after it had been repaired that the miscommunication caused the contamination.

Once the fridge was repaired and working, the controls are supposed to be hooked up to an automatic surveillance system that watches over the temperatures of several different medical apparatus. First mistake: someone neglected to connect the repaired fridge to the surveillance system. Second mistake: the blood was put back into the fridge without checking to see if the temperature was correct. The third mistake was a result of the first two. Since no alarm went off from the surveillance system (since the fridge wasn’t connected to it) no one thought to check if the fridge was indeed working properly assuming everything was all right. The temperature difference was noticed by a physical check which is done every 8 hours but was too late to save the blood.

Blood has a dollar value and 91 satchels of blood are worth $35,000. The hospital in question had to buy 71 new bags to replace those that were lost at a cost of $25,000.

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