Reader's Respond

April 1, 2010

Observing 40 years

Editor's note:
The October 2009 edition of MLO featured the poem “Observing 40
Years,” (page 43) written by Patricia Gail Box Ingram, BS, MT(ASCP), to
commemorate MLO's 40th anniversary. We inadvertently left off
some biographical information about the author. Gail Ingram trained at
Baptist Hospital School of Medical Technology in Nashville, TN, and
graduated from David Lipscomb College. She is employed as a generalist
technologist II at Jackson Hospital in Montgomery, AL. Readers can now
understand why she put together this tribute to medical laboratory


Thanks to an astute reader who pointed out an error
in MLO's February “Hepatitis numbers” article (page 22). Somehow
a few hyphens disappeared, which changes things drastically. The correct
statement from the CDC: HCV RNA can be detected in blood within 1-3
weeks after exposure. The average time from exposure to antibody to HCV
(anti-HCV) seroconversion is 8-9 weeks, and anti-HCV can be detected in
>97% of persons by six months after exposure. See

What's in a name?

Our laboratory has been a driving force in encouraging
proper patient identification protocols for many years and, yet, the
patient-identification errors we detect all too often show that much work

I enjoyed Dennis Ernst's [Washington Report] article on
page 48 of the January 2010 issue of MLO. It seems that we think
alike. I am particularly interested in his fourth citation, the article in
the Daytona Beach News-Journal from 2008 recounting the story of
Blake Oliver and Bert Fish Hospital. I was unable to locate a full-text
article online.

I find that having specific stories illustrating the
consequences of patient misidentification is very useful when trying to make
the case to healthcare workers that these issues are not abstractions and
that they could easily become involved in a sentinel event when casual
identification procedures are followed.

Our ER routinely collected urine specimens from patients
before they were admitted into the HIS. These specimens were identified only
by a handwritten name. I found a number of errors in a short period of time,
so I updated our policies for acceptable urine samples: Handwritten labels
are to include the patient's full name and DOB (two Joint Commission patient
identifiers) — and when the patient is subsequently admitted and a
computer-generated label is applied to the specimen cup, that label does not
obscure the original handwriting, and all the information matches. This
change in SOP earned me the title of “urine nazi.” I wear the title proudly.

—Name withheld by request

Dennis Ernst's reply :
The Daytona Beach News-Journal online no longer archives the
article that I first found about the death of Blake Oliver after he
received the wrong type of blood at Bert Fish Medical Center. However,
they do offer it for sale for $2.95 at .
you will find two articles listed about half way down the page. Another
brief article (free) is available at

Editor's note:  See
Washington Report  for
The Joint Commission's response to Dennis Ernst's article.