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- Thomas Wesley Williamson, MS, MT(ASCP)⇑
- Kathleen M. Kenwright, MS, MLS(ASCP)SI, MB
- Linda L. Williford Pifer, Ph.D., SM (ASCP), GS (ABB)
- Address for Correspondence: Thomas Wesley Williamson, MS, MT(ASCP), Assistant Professor, 930 Madison Ave, Memphis, TN 38163. (901) 448-6304. twillia1{at}uthsc.edu
Abstract
This is a case study of a 28 year old morbidly obese pregnant female with severe pre-eclampsia. She delivered at 32 weeks gestation by emergency cesarean section, and was discharged at three days post-surgery. The patient developed sepsis secondary to necrotizing fasciitis. She had been released from the hospital without her final complete blood count (CBC) having been reviewed by the attending physician, although it had been available for approximately 24 hours prior to her departure. The final CBC contained persuasive data suggesting that an adverse outcome could be highly probable. Discussion as to how this ultimately lethal post-analytic error might have been avoided, and perhaps prevented in the future is undertaken.
ABBREVIATIONS: CBC - Complete Blood Count, C-section- Cesarean section, HELLP- Hemolysis Elevated Liver enzymes and Low Platelet count, NICU- Newborn Intensive Care Unit, NRBC nucleated red blood cells, Ob/Gyn - Obstetrician/Gynecologist,, TJC - The Joint Commission, WBC - White Blood Cells
- INDEX TERMS
- Preeclampsia
- necrotizing fasciitis
- sepsis
- patient safety
- medical errors
- neutrophils
- and hematology
- © Copyright 2016 American Society for Clinical Laboratory Science Inc. All rights reserved.
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