Young men think old men are fools, but old men know young men are fools.
George Chapman
I have just sat through a 60 Minutes segment about a 17 year old girl who had her heart and lungs replaced with incompatible organs. She was type O and the donated organs were type A. If she was type A and the organs were type O, everything would probably have been all right, but the opposite was true, so she died despite all efforts to rectify the mistake by removing and replacing the incompatible organs.
This brought me back to a very personal experience during World War II. After army medical basic training, I was assigned to the 99th General Hospital. They sent me to laboratory technicians school at Walter Reed Hospital for 3 months. The unit then went to England to received casualties from the Normandy invasion of France. From there we went to Reims, France, where we occupied a hospital building. I was 20 years old.
I was doing a crossmatch for two patients who needed blood transfusions. The procedure is a simple one, and it is probably still done the same way. The patients red blood cells are mixed with the donor's serum, and the donor's cells are mixed with the patient's serum. After a suitable time interval, the mixtures are examined under a microscope for any clumping of the red cells. If no clumping occurs, the match is considered compatible. This was a procedure that I had done many times. In this case, I found that the matches were compatible. However, in the process of recording the numbers on the bottles of blood, I got them mixed up. If the transfusions had been performed as I had set them up, it probably would have killed one of the recipients. Fortunately, the pathologist checked the numbers and caught the error.
I was shattered at the thought that I had committed a potentially fatal error. I went to the company commander and asked to be transferred from the laboratory. He said that all he could transfer me to was latrine duty. I said "I'll take it." After spending some time cleaning toilets, I ended up back in the lab.
Pathologist George Tolstoy was a wise old man (He must have been around 40 years of age). He made it a laboratory rule that before any blood for transfusion left the lab, it had to be checked by either himself Major Tolstoy, or Private Pilgrim. He knew that I would never make that same mistake again and that I would detect it if anyone else made a similar mistake.
Everyone involved in the death of that girl will have it on his conscience for the rest of his life. Every person involved will say to himself that if only he had double checked, she might be alive today. Those people will never make that same mistake. Neither will anyone else involved with organ transplant. Doing cross matches, as they do with blood, will probably become a routine procedure, if it isn't routine already.
Because of past mistakes, clerical errors have been made very unlikely in blood transfusion because no one transcribes numbers any more. They now use pre-printed labels. This was because someone had killed a patient in the past as a consequence of a clerical error. Now, as a consequence of the death of that girl, it is extremely unlikely that a similar mistake will be made in the future.