Case Study: Blood Sample Contaminated with IV Fluid


Back

A sample was received by the Medical Technologist (MT) in the blood bank from Surgery Recovery. A two unit crossmatch was ordered. The MT spun the sample down and upon removing the it from the centrifuge immediately noticed the abnormal appearance of the serum. The fluid above the red blood cells (serum) was colorless. Serum is normally straw to yellow in color. The MT also noticed the small volume of red blood cells, which if valid, was indicative of life-threatening anemia. The MT called the nurse who drew the sample. Initially she denied drawing the sample from above an IV. After additional questioning, she admitted that she had drawn the sample above an IV. The MT asked if she had turned the IV off first, she said, "yes", had she waited five minutes, she said "no", had she discarded the first tube drawn, she said, "no". She finally said, "I'ts JUST a crossmatch". The MT then explained that the substances which are being detected during serological testing in the blood bank were diluted out with IV fluids, which could result in the death of the patient. She drew another sample. The picture below shows the initial sample collected on the right, and the properly collected sample on the left.


Last Update: November 14, 2000
Web Author: Terry Kotrla, MT(ASCP)BB, kotrla@austin.cc.tx.us
Copyright 2000 by Terry Kotrla, MT(ASCP)BB- ALL RIGHTS RESERVED