Report: Lehigh Valley Hospital gave fatal dose
Transplant patient died after series of hospital errors, state says.
Cassi Creek:
Patient Point of Care Analysis has many benefits and some justification. But in the hands of the wrong people, it can be deadly. Read the article linked above. It should scare you. Those simple little test strip readers are a boon to diabetic patients who need to know what their plasma glucose levels are. But like the people in the article above, failure to read and follow all the documentation and guidelines for analysis can result in dangerously wrong results.
The manufacturers gloss over the need to run control samples. Any real lab knows that controls must be analyzed in order to know that the strip/meter system is working correctly. Improper storage during transport can destroy the enzymatic reagents embedded in the test strips. Yet there is no way to determine that damage without running controls. The control samples must be in date and properly stored as well.
I’ve argued many times with nursing units about quality control testing and documentation records. Nursing staff don’t want to take the time to run QC samples or log the results. They are busy, often under-staffed, and care for more about patients than about quality control duties they feel should fall to the central lab staff. Lab staff are also under-staffed, busy, and don’t want to take responsibility for QC logs that were generated by non-lab staff.
The central lab never wins these arguments. But unless there is a sample collection error of some sort, the central lab is much more likely to report out an accurate and reliable result than is a POC analyzer in the hands of nursing units.
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