Description of Event or Problem · 1
ON 11/5/96, A SUPERVISOR AT THE ACCOUNT REPORTED TWO LOW HGB RESULTS ON TWO ONCOLOGY PTS, WHICH WERE OBTAINED FROM THE DEVICE. BOTH PTS WERE SENT TO THE ER AT THE HOSP ACROSS THE STREET AND REDRAWN. HIGHER HGB RESULTS WERE RECEIVED AT THE HOSP. PT #1 WAS INITIALLY DRAWN BY A HOME HEALTHCARE NURSE AT 0900 AND THE SAMPLE WAS RECEIVED BY THE ACCOUNT AT 1300. RESULTS RECEIVED WERE: HGB=4.7 G/DL;HCT=14.33%. NO CLOTS WERE NOTED IN THE SAMPLE. A HGB RESULT OF 9.6 G/DL WAS RECEIVED AT THE HOSP FROM A NEW SAMPLE. PT #1 WAS RELEASED AND SENT HOME. PT #2 WAS INITIALLY DRAWN BY THE ACCOUNT IN THE AFTERNOON AND THE FOLLOWING RESULTS WERE RECEIVED: HGB=6.9 G/DL; HCT=21.6/21.1%; AND PLT=830-836,000/MM3. PT #2 WAS SENT TO THE SAME ER AND THE FOLLOWING RESULTS WERE RECEIVED: HGB=9.4 G/DL; HCT=29.1%. PT #2 WAS TRANSFUSED AND ADMITTED TO THE HOSP FOR OBSERVATION. POST TRANSFUSION RESULTS, ACCORDING TO THE ACCOUNT, WERE: HGB=9.8 G/DL; HCT=29.8%; 760,000MM3. PT #2 HAS A CLINICAL DIAGNOSIS OF ANEMIA/MYELOPROLIFERATIVE DISEASE.