Sue Arata

Just trying to get an idea of how many Transfusion Services are having a second specimen collected when the patient has no historical group & type. We are trying to implement this in our facility as a safety feature, not as part of an e crossmatch implementation. Thank you.

We are version 6.15 in Meditech and currently use TAR for almost all transfusion documentation.  I find review fairly easy, but we have a real bull dog of an RN in our IS dept who did a great job building it, and assumes total ownership of it.  Documentation outside of TAR (in nurses' notes, in "vitals" section, etc.) is not considered compliant for non-emergent transfusions.  (Vitals entered in TAR do flow to the "Vitals" section of the EMR however). Nurses are prompted at the correct times and each timed entry includes a section asking if s/s of transfusion reaction are observed. She has included a 30 min post transfusion vitals check within the TAR record.  I review a sampling throughout each month and forward minor exceptions to dept nursing leadership; I submit Report of Events for significant exceptions.  Aside from checking for transfusion orders and labs, most everything else I need is included in the TAR documentation.  How TAR is built in OM determines how much info is available in it. Don't get me wrong, I spend a considerable amount of time in the EMR sleuthing out why we transfused someone who didn't appear on the surface to meet criteria, but that is not the fault of the TAR documentation.

We have Meditech and TAR and it is a problem. The transfusion report gives minimal information. My staff spends hours on  auditing for compliance. TAR was suppose to eliminate incomplete transfusion charts, consent, vitals ,outcome. The implementation of TAR requires checking in EMR for transfusion data . IF the data is not present we have to  search for documentation in the nursing notes. I would like a NPR report specific for TAR documentation. IF the information is not documented then it is an incomplete document. Unfortunately we do not have access to a  NPR writer and Meditech has limited options. If you manage to get a transfusion report to please can you share it.
 
 

We are a small blood bank in New York that is looking to implement the electronic Transfusion Administration Record (TAR) software in an older version of Meditech.  We (Nursing and Blood Bank) reviewed the system and like the software for issuing and transfusion of the blood products. But to review patient’s transfusion information in Meditech after the transfusion is horrible. The reports/forms are not formatted and appear mashed together. This is not acceptable Blood Bank practice.  I contacted Meditech to give me suggestions or allow me to contact any blood bank that uses the Meditech systems so they can give me suggestions. But it has been over a month and Meditech still have not contacted me.  If I do not get this issue resolved, we will have to continue documenting  transfusions on paper.  So, this is my last hope... Is there anyone that uses the electronic TAR feature of Meditech? If so, how are you auditing the transfusions and showing inspectors the transfusion information during inspection?

Someone above commented that a 2nd sample is only required in the U.S. for computer crossmatch (which used to be true). But with the 31st Edition of AABB Standards (effective April 1, 2018), this requirement was moved so that it now applies for all pretransfusion testing for allogeneic transfusions including all types of crossmatching (IS, AHG, and Computer crossmatching). This is more in line with CAP requirements and makes more sense in order to detect possible Wrong Blood In Tube (WBIT) events.
AABB Standards for Blood Banks and Transfusion Services, 31st Edition
5.14.5 Pretransfusion Testing for Allogeneic Transfusion  
There shall be two determinations of the recipient’s ABO group as specified in Standard 5.14.1.  The first determination shall be performed on a current sample, and the second determination by one of the following methods:
Testing a second current sample.
Comparison with previous records.
Retesting the same sample if patient identification was verified using an electronic identification system or another process validated to reduce the risk of misidentification.
Standards 5.11 and 5.27.1 apply.
 
Personal Note: If you intend to retest the same sample (by a different person or the same person), be prepared to show the AABB assessor your validation proving that your "another process" is actually validated to reduce the risk of misidentification (i.e. WBITs). 
 
CAP Checklist Requirements:
TRM.30575 Misidentification Risk
The facility has a system to reduce the risk of mistransfusion for non-emergent red cell transfusions.
NOTE:  Mistransfusion occurs from misidentification of the intended recipient at the time of collection of the pretransfusion testing sample, during laboratory testing and preparation of units to be issued, and at the time of transfusion.  Misidentification at sample collection occurs approximately once in every 1,000 samples, and in one in every 12,000 transfusions the recipient receives a unit not intended for or not properly selected for him/her.  The laboratory is expected to have implemented a plan to reduce these risks through implementation of a risk-reduction system.  Among options that might be considered are:  (1) Verifying the ABO group of the intended recipient on a second sample collected at a separate phlebotomy (including the recording of the result in the institution's historical record); (2) Utilizing a mechanical barrier system or an electronic identification verification system that ensures that the patient from whom the pretransfusion specimen was collected is the same patient who is about to be transfused.  Other approaches capable of reducing the risk of mistransfusion may be used.  The laboratory should participate in monitoring the effectiveness of the system that it implements.   The laboratory should also consider improvements in procedures and/or educational efforts as part of its program to reduce the risk of mistransfusion.
 
TRM.40670 ABO Group and Rh(D) Type Verification
The recipient's ABO group and Rh(D) type has been verified by repeat testing of the same sample, a different sample, or agreement with a historical type in the laboratory's records.
NOTE:  Repeat testing of the same sample may be inadequate unless the sample has been drawn using a mechanical barrier system or digital bedside patient identification system. For laboratories that employ computer crossmatching, serologic crossmatch techniques must be employed when ABO typing discrepancies are present (e.g. mixed field reactivity, missing serum reactivity, apparent change in blood type post hematopoietic stem cell transplant).

We instituted the practice of retyping the patients if their histories could not be proven. To do so, we instituted the practice of performing the retypes on a different specimen collected at a different time within the previous 24 hrs or within 1 hr of the blood type verification in the LIS. The histories are checked on every patient in the blood bank, if they do not have a historical type, the phlebotomist is sent to the patient room to collect a new lavender top tube. It does not matter the type of the patient, if they have no history, they get retyped. This practice ties into CAP TRM.30575. We have actually "caught" incorrect collections by the RN's that collected the incorrect patient and labeled the specimen with the wrong patient information.
This is our practice and we are sticking to it!
 
The other Scott

I agree that, in the case of an emergency, of course group O blood should be given - I have never argued against that and would be completely mad to so do.
No, my argument was purely that, in a normal situation, a second sample should be taken from ALL patients.

I think the point is in an emergency situation where you don't have time to either get the second sample or if you have the second sample and have identified a discrepancy then you should use group O until it is resolved.
What other option do you have? 
If it is not an emergency then of cause a third sample would be required to resolve where the error occurred as well as looking at any other patients on the same ward bled at a similar time to see if there are any other patients involved in the mix up. 
But I agree with your point that it should be all patients that have a second sample, we required 2 samples regardless of their blood groups. 

I suggest you take a moment and determine exactly why you want a second type.  Is it simply to be able to meet some outside requirement?  Is it to detect the possibility of a testing or clerical error at the bench or is it to determine if the blood in the tube did not come from the patient the test was ordered for?   While each of these is a worthy goal, by my way of thinking only one way will achieve all 3 and that is a second sample collected at a different draw.   Now you can get even more complicated if you want depending on your level of paranoia.  Must that second sample be collected specifically for this purpose or can you "borrow" one from hematology?  Must that sample be collected by a second individual or does that matter?  Must that 2nd collecting individual be left handed because the original collector was right handed?  Lastly you must determine what are the actual limitations imposed by your facility for each shift.  Are you a small facility without the staff on all shifts to actually have a second sample drawn by a second person?  Take the time to really consider all of this and then keep it as simple as you possibly can.  No one ever improved anything by making it more complicated.  

Sorry, but to my mind, these patients should also be typed twice.  Yes, they can be given group O blood (almost always safely), but what if it is a WBIT, and the D typing is wrong because of it, or an antibody is missed because the "real" patient is group O with, say, an anti-K, while the other patient bled is group O, with no antibodies present.  In addition, and incredibly rarely, what if the "real" patient is an Oh, while the patient bled is an ordinary group O.

If you have access to a maternity service, cord cells are negative for CD38, thus we use a homemade cord cell panel, which has been inexpensive and 100% successful in screening for clinically significant anti-red cell antibodies.  This drug is going to be used more frequently in initial treatment for multiple myeloma so one might as well be prepared for doing this very frequently in the future.  Fortunately these patients are not heavily transfused and only occasionally have alloantibodies.
Transfusion. 2015 Sep;55(9):2292-3. doi: 10.1111/trf.13174.
Alternatively, you can use DTT, see the above letter for references.
Daratumumab cord cell method.pdf

You should probably get used to the DTT procedure.  Hemo-BioScience offers the reagent in small aliquots that can be used easily without bothering with trying to manufacture the stuff.  There are several threads on this already on this site.  Do a search and see the discussions.   I had posted our procedure in one - let me know if it is not accessible now and I can send it to you.
The cord panel method would be nice if you are doing a lot of pts, and at least the cells will last a while.  DDT treated cells will not last long at all.  
 
 

OK, I"ll admit it. I'm stubborn. I won't give up on this sort of problem. Even though I really don't have time for it. So here's how I've persisted over a lot of years, with some success.
You really need to report all deficiencies you find, through whatever incident reporting system your facility utilizes, hopefully to quality, so that risk management comes into play. A lot of work for you, but it's the only way to get their attention sometimes or to get the attention of someone higher up who can make changes.
Do your research - check out their references, which will be nursing manuals, articles, etc. and see if they are compliant with those. Nursing standards of care and practice are everything to nursing management. They aren't much impressed w/ lab references unless there are regulatory teeth behind them. If you can throw specific regulatory references, do so. I tell them that if I'm cited during a CAP inspection, we're going to have an issue with TJC (truthfully) and that gets action here. Sometimes I have to use a back door approach. If there isn't a specific checklist item directly pointed at the problem, can you find something else that will help. Don't forget CLIA regs.
As David says, sometimes compromise is helpful. Are the expectations greater than the nursing standard of practice? If they are, that's not necessarily a bad thing, but you might get better compliance if you uncomplicate things a bit. Nurses do have heavy workloads. If you can give a little, they may meet you part way.
Education can be helpful - can you get the cooperation of your nursing education staff? CAP requires annual education for transfusion and recognition of reactions (which means I can say that we've got to do it to pass TJC). I ask them to stress that attention to vitals is a very important way to catch reactions and that adverse events have to be documented. And if you don't document, you can't prove one way or the other whether or not a reaction occurred. Whoever your inspectors are, check out the requirements for documentation and education.
My experience is that it will take a lengthy period of time for improvement and that 'continuous quality improvement' is going to be the mantra. Staff comes and goes so there are always new people to be educated and good habits will slip over time. It took me years to get buy in that we had a problem. Our first electronic flowsheet for transfusion documentation didn't have mandatory entry fields - I pushed for that and didn't get it because nursing management thought that it would 'set staff up for failure'. I found that puzzling, but had to work with what I got. I looked at patterns of deficiencies and looked for failures to follow policy and reported multiple examples. I directly emailed nurses for followup - 'Hi "name", I noticed that the "whatever was missing" was not documented on the flowsheet for your patient. Please be sure to document "whatever was missing" because it is important for regulatory compliance or patient safety or whatever reason sounded impressive. I cc'd their managers on these emails. Sometimes I cc'd an education staff member I work closely with and she makes sure that common problems are addressed as part of new nurse orientation.  We now utilize a flowsheet (Epic) that does have mandatory entry fields (Yippee!). Once they've had time to settle in with the new Epic version and I've got our new blood bank system up, I'll start looking at data again and reporting problems. Can you ask someone in the lab to help you with the chart reviews or delegate some of the reviews? There are some young techs in my lab who are eager for extra responsibility - perfect project for them.
 

You don't say who "upper management" includes, but this might help.  We struggled greatly when I first started doing the transfusion review several years ago.  The Quality Review department (all nurses) used to do the reviews and we were always at 100%, partly because they didn't audit all transfusions but mostly because they only looked at blood pressure for vitals documentation.  I couldn't believe that a nurse didn't know that temperature is part of vitals!  When I started doing it they were shocked that our compliance was <50%.  Fortunately for me, our Director of Nursing and Risk Manager were appalled and very adamant that we fix this.  It wasn't easy, but we have been at >95% for several years now.  I would enlist the help of your Risk Manager if you haven't already.  I became a pro at completing incident reports in several systems over the years, but writing up every single instance was what finally turned the tide.  The nursing managers were fed up with investigating incident reports very quickly!