Dispatcher Case Study

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On January 24, 2016, a Hospital Services Dispatcher began the selection process for neonate red blood cells for Morristown Medical Center (MMC) located in Morristown, NJ. The Dispatcher selected the units but did not verify the CMV status of the tag against the CMV status on the ABO/Rh label. The units were brought to the Technical Services Laboratory for sickle cell testing. After testing was completed, the products were returned to the Dispatch area. An electronic shipment was created in the blood establishment computer system (BECS), and a packing slip was printed. The Dispatcher reviewed and signed the packing slip but failed to have the Lead Dispatcher or an available driver complete the secondary review. The order was shipped to MMC
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