SITE SELECTION
SCENARIO:
A vein over a bruise is selected.
INDICATE:
ERROR
RISK
FIX
Error: Bruised site
Risk: Hemolysis
Fix: Choose another site
SCENARIO:
Patient says they faint but is ignored.
INDICATE:
ERROR
RISK
FIX
Error: Ignored warning
Risk: Fainting
Fix: Recline patient
Tube missing during draw
INDICATE:
ERROR
RISK
FIX
Error: Poor prep
Risk: Redraw
Fix: Gather supplies and review prior to draw
Tourniquet left >2 minutes.
INDICATE:
ERROR
RISK
FIX
Error: Long tourniquet
Risk: Hemoconcentration
Fix: Remove at 1 min
EDTA before cultures.
INDICATE:
ERROR
RISK
FIX
Error: Wrong order
Risk: contamination
Fix: cultures first
SCENARIO:
Blood drawn from arm with IV
INDICATE:
ERROR
RISK
FIX
Error: Drawing near IV
Risk: Dilution causing erroneous results
Fix: Use other arm
SCENARIO:
Tubes labeled away from bedside.
INDICATE:
ERROR
RISK
FIX
Error: Late labeling
Risk: Mis-ID
Fix: Label immediately
SCENARIO:
Tourniquet on before setup.
INDICATE:
ERROR
RISK
FIX
Error: Early tourniquet
Risk: Hemoconcentration
Fix: Prep first
SCENARIO:
Patient pumps fist.
INDICATE:
ERROR
RISK
FIX
Error: Fist pumping
Risk: ↑ potassium
Fix: Relax hand or make a small fist only
Serum after EDTA.
INDICATE:
ERROR
RISK
FIX
Error: Order error
Risk: additive carryover
Fix: serum first
SCENARIO:
Vein used on mastectomy side.
INDICATE:
ERROR
RISK
FIX
Error: Mastectomy side
Risk: Lymphedema causing dilution
Fix: Use other limb
SCENARIO:
Only name confirmed, no DOB.
INDICATE:
ERROR
RISK
FIX
Error: One identifier
Risk: Wrong patient
Fix: Use two IDs
SCENARIO:
No expiry check on tubes.
INDICATE:
ERROR
RISK
FIX
Error: No checking
Risk: Potential to use expired tubes leading to rejection
Fix: Check expiry
Needle redirected repeatedly
INDICATE:
ERROR
RISK
FIX
Error: Fishing
Risk: Tissue damage
Fix: withdraw needle + retry
Tubes not mixed.
INDICATE:
ERROR
RISK
FIX
Error: Not mixed
Risk: clotting
Fix: invert tubes