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An exceptional safety story and what I love about TeamUHN

Dr. Kevin SmithWhen we are faced with something that doesn’t seem right, we have the decision to pursue answers or let it go. We make this choice all the time in every part of our lives. Sometimes we let things go because the human mind is imperfect and we know we might be wrong. But in many cases, it’s important to trust your intuition even when you receive conflicting information. This is especially true when it comes to patient safety. In this story, nine patients were prevented from incurring a potential complication with a very high mortality rate thanks to people following their instincts and using critical thinking.

Recently, senior technologist Krista Maracle at UHN’s Blood Transfusion Lab received a daily report which identifies patients requiring irradiated blood products. There are always one or two patients in this report but for two days in a row, there were none. Shelley Oliver (Senior Technologist, UHN Blood Transfusion Lab) followed up by calling the Help Desk to see if there was anything wrong with the report. The investigation found no issue. On the third day, the report had no patients again. Very strange – so Michener alumna Selene Fernando (Senior Technologist, UHN Blood Transfusion Lab) called the respective units at Princess Margaret to ask if there were patients who should be receiving irradiated blood. In response, nurses Breanna Martin and Marianna Augustine followed up with their colleagues individually while pharmacist Melanie Cormier looked through every patient chart. They discovered there were nine patients that should have been on those blank reports. It turned out the daily report was indeed malfunctioning. Thankfully, none of the patients requiring irradiated blood had been transfused. If they had been, they could have acquired graft-versus-host disease. Many of you know how serious that would have been. The reporting system is now fixed.

I was moved by this story because it demonstrates what I love about TeamUHN – our shared and relentless pursuit of answers fueled by critical thinking, razor-sharp instincts and teamwork. We see this every day across care, research and education. Thank you everyone for all that you do.

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