Wrong Slides and Delays

         A while ago, a hospital in the network sent my department some blood parasite slides along with the patient blood sample. We noticed something was off.

         Those didn't look like thin smears for blood parasites. They looked more like standard gram stains. Instead, these were supposed to be thick smears but were prepared wrong.

         Thick smears are supposed to be like the slide in the middle of the chart. We could have remade the slides from the patient sample. Except, there was one problem. The blood sample was too old.

         The sending site waited for days before sending us the slides and blood sample. The sample collection time is crucial for this type of smear because the visibility of blood parasites is only possible at certain times of their life cycle. We had to cancel the test after contacting the medical director. Only under his approval could we credit the test and order a redraw.

         Several days later, we received a complaint from the sending site for canceling the order. This event escalated to the medical director, who had to clarify the protocol written in the SOPs. The sending site later sent fresh slides and samples stat to be run.

         In the end, it delayed patient results. I never found out what happened to the patient, but this was a less-than-ideal situation. The moral of the story is to be familiar with your SOPs. The finger-pointing will not serve the patient's well-being or your ego.

Posted with STEMGeeks