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Transfusing Blood in the OR

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I have read several threads, some maybe 10 years ago regarding this matter but I didn't see anyone really addressing the following. My question is does anyone work at a hospital where anesthesia scans in the blood unit prior to transfusion?? According to AABB 5.28.4 "The transfusionist and one other individual (or an electronic identification system) shall, in the presence of the recipient, positively identify the recipient and match the blood component to the recipient through the use of 2 independent identifiers". There is also a similar statement from CAP TRM.41300. 

We had a near miss several years ago, same situation, different place. One refrigerator being shared in the OR, 2 big cases going on, you get the scenario. To me, it doesn't matter how great the cooler, refrigerator, blood tracking .... there is no fool proof system but can we get close to one? one of the threads addressed the Joint Commissions Sentinel Event Alert regarding blood for multiple OR patients in the same refrigerator among other things (1999). This was 20 years ago!!!! Have we not improved this in 20 years???? Is it that hard to scan in a blood unit? Does it not take more than 5 seconds to do this??? The people making these computer decisions at  our facility just can't see how important this is. Geez and in this day and age of computers all I get is "Our computer system cannot currently check this and that and blah blah blah is all I hear. Calgon take me away! Sorry for the rant but I needed to get that off my chest. 

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We do not have units in a fridge in OR (or anywhere else for that matter besides the BB).  Our BB is just down the hall from OR, so our OR units are kept in the BB until needed for a specific patient  Then they are issued in a cooler.  Presumably the correct ID and read-back is done in the OR for each unit.

Scott

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This is not a popular concept but at some point we have to accept there are things we can not control.  Once the blood leaves the blood bank we are at the mercy of other humans and as long as the human factor is involved there will be human error be it unintentional or intentional.  Attempting to complicate a process will only provide inventive humans the opportunity of coming up with creative work arounds to circumvent your best of intentions.  At some point you just have to step back, do your job and hope for the best.  I had a corporate transfusion QA director who could not accept that human error could not be completely eliminated with out eliminating human involvement in the process.  Her directives became horribly complex solutions with multiple, redundant checks and balances only resulting in increasing problems.

Bottom line, pick your battles and fight those you have a reasonable chance of winning.  Make suggestions, offer insight, provide training opportunities but at the end of the day realize that you have to accept some things are simply beyond your control and even your influence.

On that happy note I'll step off my soap box and stop my philosophical ramblings.  :coffeecup: 

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If documentation of proper blood handling for transfusion is not appropriate, I am pretty sure that the inspectors will not care whether it's happening in the Blood Bank in the Lab or in OR.  This is healthcare, after all, and this is my hospital.  

I do think it is worthwhile to try to correct deficiencies.  It make seem like a sisyphean task at times, but one cannot just give up on this stuff just because we "are at the mercy of human beings".  (We should all be used to that by now!) 

I do think that efforts should be concentrated on making things as simple as possible, not only for ourselves, but for those other humans in all the other departments that we work with everyday.  I do think its worth the effort.

Scott

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Thank you everyone for your responses. As wrong as it sounds, it gives me some peace knowing that there are others going through or have gone through the same battles. And like John stated there are others 'stepping in' and just complicating the situation for blood bank with solutions that make matters worse, not better. I really appreciate the pep talk and I will pick my battles carefully and continue to do the best that we possibly can for the sake of our patients that we serve. I feel better now :lol:

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Posted (edited)

I agree that blood bank refrigerators in the OR (or anywhere else) are accidents waiting for a place to happen. We use a temperature monitored and controlled cooler system so that the blood for the patient in the OR is sitting right next to the anesthesiologist.  Have had no mistransfusion accidents in the OR in the close to 40 years I've been here.  In the hospital where I trained there was an OR refrigerator and we had mistransfusions every few months.  Case closed.

Edited by Neil Blumberg

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Legacy is on the BPAM system which started a couple years ago which is based on a matching system. The blood being dispensed has the order scanned using the MR#, the accession # and the unit number. When the unit is to be transfused, the transfusionist scans the Patient's arm band and the unit to be transfused and there some computer field they are in and if everything is okay they can move on and if not it is a hard stop. There is an emergency over ride for cases where emergent uncrossed blood is sent that is another story

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Does anyone audit the units transfused in the OR? How does the individual units transfused in the OR go into the patients record? Does the units go on a flow-sheet and someone transcribes this into the chart? Does the whole flow-sheet get scanned somewhere in the chart? I'm just trying to get as much information prior to a meeting about this. It seems like most are using coolers in the OR which seems 'more safe' than one refrigerator to 'share'. I'm willing to trust the process once it leaves the blood bank as long as that is compliant with AABB and CAP.

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I work in cardiac surgery unit.It is very simple for us.We have schedules with the patients every day and we know every case in particular.Every unit of blood is labeled with the pacient's ID,ABO/Rh group,crossmatch number,the name of lab worker who performed the crossmatch and also the date of the test.
We have 3 OR's and every time they need units of blood they call in our unit(which is only 2 floor distance) and we transport the units to them.They perform Bedside ABO/D test before every transfusion!All the dates from the blood unit are transcripted in patient's chart manually (we do not have a computer scan for that).
So far everything works great.
I am from east Europe country. 

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Posted (edited)
On 4/22/2019 at 8:53 AM, slsmith said:

Legacy is on the BPAM system which started a couple years ago which is based on a matching system. The blood being dispensed has the order scanned using the MR#, the accession # and the unit number. When the unit is to be transfused, the transfusionist scans the Patient's arm band and the unit to be transfused and there some computer field they are in and if everything is okay they can move on and if not it is a hard stop. There is an emergency over ride for cases where emergent uncrossed blood is sent that is another story

Does the O.R ever tell you that the Pt's armband is "inaccessible" because it is "under the patient and contained within the sterile field"?  We use an armband system for our BB patients and we get told that occasionally when we need to transfuse in O.R. and they didn't get the armband number before they covered up the pt.  The RN usually winds up crawling under the pt's table.  What does your O.R do in that case?  Especially since they are having to do a barcode read of that band?

We use coolers for our O.R. deliveries (one pt per room) and I never want to even discuss the introduction of an O.R. refrigerator.   Anything giving in the O.R. is documented in the anesthesiologist"s records, which are also part of the electronic record.

Edited by cswickard
add on

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18 minutes ago, cswickard said:

Does the O.R ever tell you that the Pt's armband is "inaccessible" because it is "under the patient and contained within the sterile field"?  We use an armband system for our BB patients and we get told that occasionally when we need to transfuse in O.R. and they didn't get the armband number before they covered up the pt.  The RN usually winds up crawling under the pt's table.  What does your O.R do in that case?  Especially since they are having to do a barcode read of that band?

We use coolers for our O.R. deliveries (one pt per room) and I never want to even discuss the introduction of an O.R. refrigerator.   Anything giving in the O.R. is documented in the anesthesiologist"s records, which are also part of the electronic record.

We had situations like you describe a few years back.  Now checking the Blood Bank (and hospital) armbands are part of the "time-out" check-off before the patient is strapped to the table.  The ID info on the bands are recorded so it is available at all times during the procedure.

Scott

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We just recently initiated scanning for blood products in the OR (Epic). Because blood products are not often transfused in the OR here, I foresee that the problem will be that anesthesia will get 'rusty' and find it difficult to utilize scanning. Too easy to forget details for something you rarely use.

The first place everyone calls for assistance with BPAM is the lab and we generally can't help them - not something we've been trained to do, though we've learned some basics in self-defense.  BPAM looks different in the OR version, so the tricks we know are probably not going to be very helpful. If blood is given frequently in the OR, I think it would work fairly well, The OR version of BPAM is clunky, but workable. In a mass transfusion situation, it may not be useable because it could slow things down to much.

No refrigerators or coolers in use here. We issue units as requested, with positive patient ID provided by the runner. For routine situations, we have a specific document that prints for Epic for each unit. In urgent/emergent situations, they bring us a chart sticker. No patient ID, no blood. We will hand deliver units to the OR for emergent situations, if we have enough staffing to do it. Sign out would be performed by two blood bankers in that situation.

 

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I have had this conversation numerous times with Anesthesia manager - do we really have to have 2 people verify? Yes. Stop asking.

As for scanning, we have Epic BPAM which does not function in the OR. OR has their own process that does allow scanning of units during massive transfusion but it isn't perfect. If they scan the units from the cooler and somehow the unit isn't transfused and is returned to the BB, there seems to be a glitch where unit status in Epic thinks the unit was transfused when it actually was not and did not update when returned to the BB.  Later, when trying to scan for another patient, BPAM gives a warning "Unit not intended for this patient".  This statement is an almost guaranteed nurse "freak-out."

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On 4/22/2019 at 7:38 AM, Neil Blumberg said:

I agree that blood bank refrigerators in the OR (or anywhere else) are accidents waiting for a place to happen. We use a temperature monitored and controlled cooler system so that the blood for the patient in the OR is sitting right next to the anesthesiologist.  Have had no mistransfusion accidents in the OR in the close to 40 years I've been here.  In the hospital where I trained there was an OR refrigerator and we had mistransfusions every few months.  Case closed.

This is what we've always done.

Are you familiar with the BloodTrak system?  If so, what do you think of it?  We don't have it, but the Blood Bank Manager put one in the budget.

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On ‎4‎/‎21‎/‎2019 at 10:10 AM, John C. Staley said:

This is not a popular concept but at some point we have to accept there are things we can not control.  Once the blood leaves the blood bank we are at the mercy of other humans and as long as the human factor is involved there will be human error be it unintentional or intentional.  Attempting to complicate a process will only provide inventive humans the opportunity of coming up with creative work arounds to circumvent your best of intentions.  At some point you just have to step back, do your job and hope for the best.  I had a corporate transfusion QA director who could not accept that human error could not be completely eliminated with out eliminating human involvement in the process.  Her directives became horribly complex solutions with multiple, redundant checks and balances only resulting in increasing problems.

Bottom line, pick your battles and fight those you have a reasonable chance of winning.  Make suggestions, offer insight, provide training opportunities but at the end of the day realize that you have to accept some things are simply beyond your control and even your influence.

On that happy note I'll step off my soap box and stop my philosophical ramblings.  :coffeecup: 

I agree -- you have to make it hard to do the wrong thing (and thus easy to do the right thing).

I've heard stories during a nearby terrorist event that coolers of blood were just going out everywhere and anywhere; whoever came down seeking blood got it. Tragedy and mistakes, unfortunately, are what drives policy adjustment. Individually assigned coolers and labels was the fix for that one, and it seems more compact and more difficult to switch pts compared to a shared fridge, but who knows. Chalking dangerous misses to "oh, that's just how humans be" seems problematic  :confuse:

On ‎7‎/‎31‎/‎2019 at 1:34 PM, applejw said:

As for scanning, we have Epic BPAM which does not function in the OR. OR has their own process that does allow scanning of units during massive transfusion but it isn't perfect. If they scan the units from the cooler and somehow the unit isn't transfused and is returned to the BB, there seems to be a glitch where unit status in Epic thinks the unit was transfused when it actually was not and did not update when returned to the BB.  Later, when trying to scan for another patient, BPAM gives a warning "Unit not intended for this patient".  This statement is an almost guaranteed nurse "freak-out."

There can also be glitches and write-over problems with XM status when the doctors are attempting to assign units to their pts, especially in regards to emergency released units. We have interface problems with HCLL to EPIC -- it's fairly easy to use an UNXM record to then try to EXM.

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