This case deals with failure to provide irradiated blood for patients with special transfusion needs such as those being treated with fludarabine.
Provide 4 concrete examples of how these errors may occur.
Concrete examples of how patients on fludarabine therapy may received incorrect (un-irradiated) blood include:
- Ordering physician does not recognize that patient needs irradiated blood
- Need for irradiated blood does not follow the patient from facility to facility
- Need for irradiated blood is not flagged in the laboratory information system (LIS)
- TS laboratory fails to retrieve patient history
- LIS fails to identify patient as needing irradiated blood