The Incident

1
Cyclosporine Whole or skim!
By Marc Hardy
2
Case Details

• My error
• Measuring cyclosporine
• 3 controls and a patient specimen
• Prepared everything according to plan

3
Cyclosporine

• Immunosuppresant
• Transplant therapy
• Found in RBCs, WBCs and in plasma
• Adverse effects
• Nephrotoxicity, hypertension, neurotoxicity

4
The Incident

• EDTA tube
• Blood separated
• RBCs instead of whole blood
• Analyser detected a fault in patient sample
• QC material was correct though

5
Resolution

• Senior biochemist ? ? Something amiss
• Too high RBC
• The biochemist repeated the testing procedure
  from start
• Hooray!... Patient test results ok

6
Releasing the Wrong Results

• What would have happened if incorrect results had
  been released?
• Patient dose altered
• Not enough drug
• Rejection
• Too Much
• Adverse effects