The missing urine sample

I worked over Christmas. The day after Christmas a concerned mom brought in a little girl with a fever. I suspected a urinary tract infection as the cause and suggested we get a sample of urine. Since she was not potty-trained, the recommended method for obtaining a noncontaminated sample was to catheterize her. Of course, this is painful and unpleasant, but mom consented, given that it was the best way to be sure this was what was wrong. Two hours after the sample was obtained, I was surprised that a urinalysis result was not back yet. I called the lab and was informed they never received the sample! After several frantic phone calls, the sample was located. It turns out it was not lost. It had been processed both for culture and analysis.

This got me thinking. Snafus happen in every work setting: files get misplaced, entries posted to the wrong account, names mis-spelled, what have you. However, when a sample is obtained at the cost of pain to a little child, it smarts so much if that sample is unretrievable. Clinical information is obtained at the cost of pain and risk to a patient: a lumbar puncture to obtain cerebrospinal fluid, catheterization to obtain a urinary sample, blood draws. I guess everyone thinks their particular work environment is special and I am not exempt from that bias. I'm just glad we found the specimen and could process it correctly. She did have a urinary tract infection and she is being treated. All's well that ends well.