Lab technician’s failure to follow procedures and attempts to thwart investigation broke high standard of trust needed in managing blood supply
An Alberta arbitrator has upheld the dismissal of a Canadian Blood Services (CBS) technician for her disregard of protocols and attempts to cover it up, finding the worker couldn’t be trusted to maintain the high standards required for managing the blood supply.
The worker was hired by CBS, the national blood collection and processing organization, in October 2003 to be a laboratory attendant and team lead. The position included assignments of end labelling, which is the final processing step before units of blood are released back into inventory for transportation to hospitals.
End labelling of units of red blood cells, once they’ve been separated from other components in blood, is set out in a standard operating procedure document that is distributed to all staff, who are trained on it and expected to know it. The procedure includes the stipulation that a unit of red blood cells cannot be kept out of refrigerated storage for more than 30 minutes — after that time, there is a risk of bacterial contamination. As a result, laboratory attendants were only supposed to retrieve the number of units they could label within 30 minutes. This was also specified in standard operating procedures.
Laboratory attendants use software to test the suitability of the blood component and print labels. Following a visual inspection, the units are labelled and returned to refrigerators. It typically takes laboratory attendants about 30 seconds to complete end labelling for a unit of blood. At the conclusion of an end labelling session, they must complete an end labelling record to confirm they have complied with the time-limit rule for each batch and fill out the timed intervals for sessions. The form includes a warning to check elapsed time during the labelling session to ensure it will be completed during the acceptable timeframe.
On Aug. 22, 2015, a supervisor was reviewing a software-generated report for a labelling session from the previous day that the worker had performed and found the time the red blood cell units spent out of storage didn’t match with the times recorded by the worker on the end labelling record. According to the generated report, the labelling session lasted 36 minutes, which exceeded the acceptable limit for red blood cell units to be out of storage. A total of nine units were affected.
Further investigation showed that the worker didn’t follow standard operating procedure for units that had been out of refrigeration past the time limit, which was to place the units back in the refrigerator, notify a supervisor about it, and prepare a non-conformist report (NCR) that would confirm the units of blood were contained and segregated from outgoing blood products. However, since the worker hadn’t filled out an NCR and didn’t record that the blood units exceeded the time limit, three of the units involved were distributed to hospitals.
The supervisor quickly created an NCR and segregated the six other units involved. The three that had been distributed were retrieved before they were used.
Worker initially played dumb
The assistant manager of quality assurance began an investigation and met with the worker and the production manager on Sept. 16, following the worker’s return from a scheduled vacation — there was an attempt to schedule the meeting before the worker’s vacation, but the worker declined. He was particularly concerned about whether the false labelling was an isolated incident or had happened before. The worker was unable to explain the discrepancy between the software report and her end labelling record, but said another staff member may have taken blood products back to the refrigerator for her. This didn’t make sense to the assistant manager since the electronic records indicated the time limit had still been exceeded, and a check with other attendants on duty revealed this wasn’t the case.
The worker also said she couldn’t recall any other occasions where she hadn’t followed proper end labelling procedures, but mentioned one instance two or three years earlier when she had falsely documented a batch of plasma units that had exceeded the time limit so the plasma wouldn’t be disposed of.
A second meeting was held two days later, when the worker said she had removed nine red blood cell units from overloaded trays from the refrigerator and placed them on the middle shelf of her cart. She said she completed the end labelling in 30 minutes and put the trays back into the refrigerator, but realized she had forgotten to label the units in the middle shelf of the cart. She took them back to her workstation to label them, though acknowledged she knew this would put the units beyond the time limit. She also mentioned she was feeling stressed that evening, as she had “a lot of things going on,” including her dog passing away earlier that week.
CBS determined that the worker was dishonest when she falsely represented that the nine units of blood were a safe product, which posed a safety risk to the blood products and patients who might receive them. The worker then compounded her dishonesty by trying to shift the blame to co-workers when she indicated she knew what had happened in the second meeting. CBS terminated the worker’s employment effective Sept. 25, 2015.
The union grieved the dismissal, arguing it was too severe under the circumstances for a long-term employee without previous discipline. It also pointed to another incident involving another laboratory attendant who had recorded blood units returned to the refrigerator two minutes earlier than they actually were after running into a problem with the label printer. The actual time out of storage in that instance was right on the 30-minute time limit, and that attendant received a one-day suspension for the discrepancy.
High standards must be maintained
The arbitrator noted that CBS had a progressive discipline policy but that policy allowed for bypassing the steps in more serious cases. He also noted that the worker should be given credit for disclosing the earlier incident, but it wasn’t a timely disclosure. Given that she repeated the earlier misconduct, there was a “serious trust concern that she might fall into a similar pattern again if she finds herself in a situation where she is short of time,” the arbitrator said.
In addition, the arbitrator noted that the worker had admitted she clearly knew that she was outside the 30-minute time limit when she labelling the nine units in question, and her actions “were not just negligent but do amount in my view to an act of deception on her part to bypass the established end labelling protocols,” said the arbitrator.
The arbitrator also found that as a team lead, the worker had higher standards of performance and leadership, including ensuring proper procedures are followed and documenting non-conformance issues — which in this case, the worker didn’t follow herself. The worker also knew there was an investigation into her actions, but put off efforts to schedule a meeting until she was back from vacation — suggesting the worker “was more concerned about her vacation than any potential disciplinary investigation.”
The arbitrator found more reason for concern about trusting the worker’s job given that the position involves “the ability to completely focus on the job at hand. The (standard operating procedure and good documentation practices) are strict guidelines that must be precisely followed or risk potentially disastrous results of contamination in the blood supply.” The worker’s explanation indicated she had difficulty with focusing on her task, skipped reporting her error, and was evasive about it in the face of CBS’ investigation, which cast doubt on future trust in her, said the arbitrator.
“The (worker’s) 11 years of service and otherwise discipline-free record unfortunately do not tip the scales in favour of reinstatement when there is such grave doubt concerning her ability to be honest about her work going forward,” the arbitrator said in dismissing the grievance and upholding the worker’s termination. “This is an industry that simply cannot assume any risk of employing an individual who does not show they are committed and honest about following the protocols required to maintain a safe blood supply.”
For more information see:
• Canadian Blood Services and HSAA (Serafin), Re, 2018 CarswellAlta 895 (Alta. Arb.).
