Record number:
124
Adverse Occurrence type:
MPHO Type:
Alerting signals, symptoms, evidence of occurrence:
Wrong size HV found in surgery. (Mislabelling)While a patient was in the OR, the HV allograft was being opened when it was discovered to be much smaller than the size on the label. Luckily, another HV of the correct size was available at a nearby hpospital and was used. The patient had unnecessarily been in the OR and under anesthetic for longer than needed. (unreported but found in tissue bank adverse event files)
Demonstration of imputability or root cause:
Discovered in the Hospital