Horror Stories from Pathology Informatics: Typos, Transfusions and Trouble
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Horror Stories from Pathology Informatics: Typos, Transfusions and Trouble
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A single misspelled name created a duplicate medical record, hiding critical transfusion history and setting the stage for a serious delayed hemolytic transfusion reaction. In this installment of Horror Stories in Pathology Informatics, Alexis Carter, MD, FCAP, and Mandy O'Leary, MD, FCAP, examine how a patient registration error disrupted access to vital blood bank information for a patient with sickle cell disease. They discuss the importance of accurate patient identification, maintaining access to historical laboratory data, strategies for managing duplicate records and system downtime, and the safeguards laboratories use to protect patients from transfusion-related harm. The case highlights how even a seemingly minor data entry mistake can have major clinical consequences and offers practical lessons for laboratorians, informaticists, healthcare leaders, and patients alike.