jalomahe

Another thought on the subject. I work for a hospital that is a part of a multiple facility group. We have two primary care hospitals and multiple off site clinics and physician outreach. We have a CORPORATE policy that governs what constitutes 2 patient identifiers anywhere within the system whether it is for lab purposes, dispensing medications, or performing invasive procedures. This gives us the basis for our own internal patient identification policy. The corporate policy came about due to the JC's focus on patient safety, this makes it easier when we deal with other entities i.e. nursing about rejecting a specimen that they failed to label properly. Then using this policy as the base we created a laboratory policy which was approved by all of the laboratory services so that labeling requirements are the same whether they are for transfusion service or for chemistry. This same policy is then used throughout the corporation for laboratory specimen collection. If you go to any of our facilities you will find the same policy in all of their manuals. The policy is also posted on our corporate intranet in our department customer guide.

We do NOT call all STATS. Our LIS prints STAT results on the nursing unit as soon as they are resulted. When the clerk gets the printout then they know blood is ready. No other section in our lab calls STAT results for the same reason. They only call if they have a critical (life threatening) result. Besides, frequently our orders are for STAT testing but not necessarily STAT transfusion i.e. pt going to surgery and they want blood available for surgery if needed. Nursing of course can request that we call as soon as blood is available. For short expiration product i.e. pooled platelets we DO call as soon as we have them ready and, if they don't want them sent immediately, we give them the expiration time, When we use the tube system to send blood we ALWAYS call the pt's nurse or the nursing unit it is being sent to. Who we notified is then documented in the LIS as part of the issuing information in case of any problems or questions later. Creates a permanent record without having to save a lot of paper files.

Cornelia Would it be possible for you to email me the information also? Janet_Helton@Trihealth.com

We have seen an increase in positives, always Cell I, when we run the Ready ID it is either all negative or occassionally it will react with cell 14. We have referred the problem to Immucor and they are researching it. If you haven't already contacted them, I strongly urge you to do so.

Interestingly enough I just asked this question (last week) of the CAP. We have a similar situation. Outside contract performs the Therapeutic Pheresis, our transfusion sevice's only involvement is in supplying the product. The official response from CAP. Answer it as N/A because our transfusion service is not doing the procedure. YEAH! Also, if you are not listing it in your Activity Menu-Scope of Service, it will not print in your Customized Checklist and therefore the inspectors should not even have the questions to ask! Jan

We handle approximately 3000 specimens per month with the specimens coming from off site locations as well as in house locations. Depending on where the specimen was collected and by whom the labeling varies. The second label is attached after the original label is verified by a blood bank tech. The second label is necessary in order to provide a barcode that the analyzer can read. The barcode can also be used with a handheld scanner at the manual benches when accessing the patient in the LIS. A root cause analysis was done and the error was deemed to be human error secondary to multiple distractions. So how do we create a 'fix' for that? I don't see that we can. That is why I'm trying to convince those over me that the FDA would find it acceptable if we did re-education and monitering.

We had an incident occur as follows: Two specimens were collected by nursing and properly labeled by nursing using labels provided by registration (contains all pertinent pt identification information and then some). Both specimens come to the transfusion service. Orders are located in the lab computer system, received and labels printed. While attaching the lab labels to the specimen the tech is interrupted (multiple times) and in the course fo labeling switches labels with tubes so that label A is attached to specimen B and vice-a-versa. Even though the tech who labeled the tube left the name and id number from the original label exposed the error was not caught by the other tech performing testing that shift. Consequently one of the pt's received an ABO incompatible unit of blood (it was caught and stopped after 100cc infused). Pt survived. FDA notified etc. We are now at the point of coming up with a way to keep this from happening again. We have a policy in place that states that at the time a new label is being attached that both the patient name and id number on BOTH labels MUST be MATCHED, then the label may be attached to the tube. However, our supervisor feels that the FDA will want us to come up with something new to prevent this from happening. By the way this is the first time I can remember this happening in our labs and I've been here for over 20 years. Does anyone have any other policy, procedure or method they use when putting a new label on an already labeled specimen? Sorry this is so long and thanks in advance for any ideas, help.

We just implemented a new MTP in our lab to include scenarios where MDsor departments may be unfimiliar with the process. If we have given 5-6 pRBC in under an hour the tech will ask if the MD wishes to call an MTP. If the answer is 'no' then the tech will notifiy the Transfusion Service Medical Director (or pathologist covering) to inform them of the situation. That way the can intervene MD-to-MD if necessary. Our problem in the past is that nursing/MDs don't like it when we start asking them questions. They want us to just keep throwing product at them without knowing what's going on. Putting the med director/pathologist in the loop helps alleviate this. Also when we instituted the new policy we did short presentations to various nursing departments during some of their mandatory education sessions. This allowed them to ask question of us and find out that we really do have a need to know and that we can help them get ahead of the patient's bleeding to help stabilize the situation, instead of always playing catch up.

Over zealous CAP inspector who thinks that his way is THE way so, since this was our first inspection after going live on the Galileo, I just wanted to see what other Galileo users were doing.

Is anyone out there who is running a Galileo performing QC on receipt for Ready Screen, Ready ID, Extend I, Extend II etc plates to prove the reactivity of each of the wells? If you are performing this type of QC what are you using for your controls? Thanks for any input you can give would be greatly appreciated.

If we are doing the DAT due to a positive antibody screen in anticipation of possible transfusion we will do an eluate IF it is IgG. That way we have a baseline to compare to when/if we have to do the patient in the future. If we are doing the DAT where the physician has ordered it and the patient has no transfusion history, then we do not perform an elution. The physician would have to request one. The physician ordering an elution, as you might imagine, rarely happens. Just remember that however you decide to set your policy up you must have it clearly defined as to when you will perform an elution (or any test) reflexively based on other testing and that information needs to be communicated to physicans that use your lab. Under federal guidelines, you cannot perform testing without a written order from a licensed practioner. We do this by including in our Laboratory User's Manual a table that lists "Reflexive Testing" and it gives the what the primary order is and then what the reflexive order would be and then under what circumstances the reflexive order is performed i.e. Primary Reflexive Circumstance for Reflexive Antibody Screen Antibody Identification Antibody Screen is positive This reflexive order list is circulated to the medical heads of all departments and distributed to the physicians we have outreach contracts with. jlmh