Jump to content

Recommended Posts

So...on the topic of doing a 2nd ABO type check: currently our hospital will typically use the same sample that is used for the TS/crossmatch, with another tech (if available) doing the 2nd retype. Occasionally, we will have a CBC tube drawn at a different time, utilized for the 2nd retype. If the second retype is done by the same tech, an IS XM must be done (no electronic XM). Obviously, using the same tube, even with different techs, does not ensure positive patient identification, only that the blood type was resulted correctly.

The hospital is reluctant to require a second specimen to be drawn for fear of lower patient satisfaction scores. One of my coworkers suggested implementing a process where there will be a 2-person verification of the patient identification. My question is: does anyone else do this? and if yes, would you be willing to share your procedure so I can discuss implementing a new process with my pathologist?

Thank you in advance for any assistance you may be able to provide.

Sue Arata

Share this post


Link to post
Share on other sites


We do not test a different specimen.  Currently regulators in the US only require a second ABO test (in order to release "electronic crossmatched" units).  We test the same specimen twice, unless we have a previous record.

However, we DO use a BB armband specific for BB specimen draws and transfusions.   The phlebotomist applies it and it must be used when ordering, issuing and transfusing blood products.

Scott

Share this post


Link to post
Share on other sites
Posted (edited)
3 hours ago, SMILLER said:

We do not test a different specimen.  Currently regulators in the US only require a second ABO test (in order to release "electronic crossmatched" units).  We test the same specimen twice, unless we have a previous record.

However, we DO use a BB armband specific for BB specimen draws and transfusions.   The phlebotomist applies it and it must be used when ordering, issuing and transfusing blood products.

Scott

Testing the same specimen twice may detect some internal testing errors, but will not detect WBIT (Wrong Blood In Tube).

4 hours ago, Sue Arata said:

The hospital is reluctant to require a second specimen to be drawn for fear of lower patient satisfaction scores.

You need to gather some data to show how many patients would be impacted by collecting a second blood sample. 

Ask these questions, "How many patient admits annually?", "How many patient admits required blood bank testing?" (at my facility the calculated percentage was 11%), "How many patient samples type as Group O?" (at my facility the calculated percentage was 55% and we don't draw a second blood sample on these patients), "Of the non-Group O patients, how many had an independently collected blood sample in Hematology that could be used for the second ABO blood sample" (in our facility that was calculated to be 16%).  

So for every 1000 patients admitted annually, 100 (I'm using 10% for sake of simple calculations) would require blood bank testing of whom 45 (100-55) would be non-group O, 7 (45 x 0.16) would have a blood sample in hematology, leaving  38 (45 - 7) or 3.8% (38/1000) patients requiring a second sample to be collected.  

Using this kind of data will give you a much better grasp of the impact of routine performance of a second ABO determination on all patients for whom a Type and Screen or a Type and Crossmatch is ordered.

Edited by Dansket
added "admitted annually"

Share this post


Link to post
Share on other sites

Considering how often inpatients get stuck I am not sure they would notice the 2nd check especially if appropriate CBC tubes are looked for and used.  

Share this post


Link to post
Share on other sites
11 hours ago, Dansket said:

"How many patient samples type as Group O?" (at my facility the calculated percentage was 55% and we don't draw a second blood sample on these patients)."

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.

Share this post


Link to post
Share on other sites

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.  :coffeecup:

Share this post


Link to post
Share on other sites
15 hours ago, Malcolm Needs said:

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.

Your post suggests that patients who initially type group O should be tested a second time for not only ABO, but also Rh and Antibody Screen.  I assume you would include the same testing (ABO, Rh and Antibody Screen) for non-Group O patients. I disagree.

Does anyone (US and UK) in this forum repeat the Antibody screen on the same sample or a newly collected blood sample?  Repeat the Rh?

The concept of a second ABO typing did not emerge until after the "Computer Crossmatch" became an alternative method (to the serological crossmatch) approved by the FDA in the late 1990’s.  Repeat testing of the same sample or a newly collected blood sample for Rh and Antibody screen was not required by the FDA, AABB or the CAP.

A second ABO typing is intended to be a serological alternative to the Immediate-spin Crossmatch to confirm the patient's ABO determination when a "Computer Crossmatch" is done. This creates a process that is similar to that done for donor units, i.e., blood type determination by donor center and blood type confirmation by the Transfusion Service. 

In the absence of a "Computer Crossmatch", a serological Immediate-spin Crossmatch is required to detect ABO incompatibility between donor and recipient and most patients are transfused based on a single ABO determination without any repeat testing for Rh or Antibody Screen.  

Share this post


Link to post
Share on other sites
Posted (edited)
6 hours ago, Dansket said:

Does anyone (US and UK) in this forum repeat the Antibody screen on the same sample or a newly collected blood sample?  Repeat the Rh?

 

Current UK guidelines stipulate "Unless secure electronic patient identification systems are in place, a second sample should be requested for confirmation of the ABO group of a first time patient prior to transfusion, where this does not impede the delivery of urgent red cells or other components." 

As per the recommendation only ABO type is required to be repeated, repeat antibody screen is not required.

In any case of urgent blood request group O blood is usually used if the 2nd sample is not available. When this recommendation came in in 2012 it did cause a lot of discussions regarding the increased use of group O blood at the time. 

 

Edited by srichar3

Share this post


Link to post
Share on other sites

As the vast majority of hospitals (and Reference Laboratories) in the UK use column agglutination technology and automation, it is almost impossible to perform a second ABO without either a second D type or wasting a column or more than one column.  But, my point was that, if a patient groups as O the first time, and A, B or AB the second time, then, it is obvious that either the first bleed or the second bleed was WBIT.  Why should it be assumed that, if the person types as group O the first time, that is both correct and that it is automatically safe to give group O blood?  If anyone does, I advise them to read the posts of Dr Neil Blumberg on ABO mismatched, but apparently compatible transfusions.

Share this post


Link to post
Share on other sites
Posted (edited)
31 minutes ago, Malcolm Needs said:

But, my point was that, if a patient groups as O the first time, and A, B or AB the second time, then, it is obvious that either the first bleed or the second bleed was WBIT.  Why should it be assumed that, if the person types as group O the first time, that is both correct and that it is automatically safe to give group O blood?  If anyone does, I advise them to read the posts of Dr Neil Blumberg on ABO mismatched, but apparently compatible transfusions.

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. 

Edited by srichar3

Share this post


Link to post
Share on other sites

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.

Share this post


Link to post
Share on other sites
On 6/8/2019 at 1:36 AM, Malcolm Needs said:

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.

You have ignored my question regarding repeat antibody screen on second blood sample in accordance with your statement above, "...or an antibody is missed because the "real" patient is group O with, say, an anti-K …"  How would this scenario be detected unless you repeated the antibody screen on the second blood sample, in that in the UK and US, only testing for ABO is required?

2 hours ago, Malcolm Needs said:

As the vast majority of hospitals (and Reference Laboratories) in the UK use column agglutination technology and automation, it is almost impossible to perform a second ABO without either a second D type or wasting a column or more than one column.  

Gel cards are available in the US that contain only anti-A,B or anti-A and anti-B.  These gel cards are used routinely to confirm the ABO type of donor units received by the Transfusion Service.  Gel cards containing anti-A,B are used to confirm donor units labeled group O and gel cards containing anti-A and anti-B are used to confirm donor units labeled group A, group B and group AB.

Share this post


Link to post
Share on other sites

My apologies Dansket.  You are quite correct that our Guidelines do not require a second antibody screen.  I went "over the top" with that one.

In the UK, however, the Blood Services guarantee that what is written on the bag label is what is in the bag, and so there is no requirement to type the donor units upon receipt.  In addition, there is no requirement to test patients' blood with anti-A,B, and so our CAT cassettes reflect that.  I attach a photograph taken from the web.  The cassettes normally used in the UK (although these are from BioRad - other suppliers are available) are of the type bottom right for confirmation samples.

ihd_bld_grp_abo_rhd_monoclonal_antibodies_category.jpg

Share this post


Link to post
Share on other sites
Posted (edited)
8 hours ago, srichar3 said:

Current UK guidelines stipulate "Unless secure electronic patient identification systems are in place, a second sample should be requested for confirmation of the ABO group of a first time patient prior to transfusion, where this does not impede the delivery of urgent red cells or other components." 

As per the recommendation only ABO type is required to be repeated, repeat antibody screen is not required.

In any case of urgent blood request group O blood is usually used if the 2nd sample is not available. When this recommendation came in in 2012 it did cause a lot of discussions regarding the increased use of group O blood at the time. 

Do the UK guidelines state how the second sample should be tested for ABO?  If so, which tests are required?

In the US, for the second ABO when Computer Crossmatch is done, the AABB currently requires both red cells and plasma/serum be tested and the CAP does not specify required testing for ABO Confirmation (red cells and plasma/serum, red cells only or plasma/serum only).

Edited by Dansket
added statement

Share this post


Link to post
Share on other sites
Posted (edited)
8 hours ago, Dansket said:

Do the UK guidelines state how the second sample should be tested for ABO?  If so, which tests are required?

In the US, for the second ABO when Computer Crossmatch is done, the AABB currently requires both red cells and plasma/serum be tested and the CAP does not specify required testing for ABO Confirmation (red cells and plasma/serum, red cells only or plasma/serum only).

In the past we always used to test the second group with just a forward group but when the requirement for 2 samples came out in 2012 most labs changed to doing two full's groups on the first 2 samples, then forward only on any subsequent samples. 

4.3.1. ABO grouping.
i. A full ABO group comprises a forward group and a reverse
group; the forward group should be performed using
monoclonal anti-A and anti-B blood grouping reagents,
and the reverse group using A1 and B reagent red cells.
ii. A full group must be performed on all samples from
first time patients, with the exception of neonates, where
the reverse group is unlikely to be helpful, as any ABO
antibodies are likely to be maternal in origin.
iii. Consideration can be given to omitting the reverse group
on subsequent samples, where secure, fully interfaced
automation is used and a risk assessment has been
undertaken to ensure that the forward group is not
compromised. The risk assessment should include the
possibility that the first sample may have been taken from
the wrong patient, an event estimated to occur at a rate of
1:2000 samples (Dzik et al., 2003; Murphy et al., 2004).
iv. The following should apply before consideration is given
to omitting the reverse group:
• There should be no manual intervention or manual
editing of results;
• The current cell group must be identical with the
historical record;
• There must be at least one valid historical record where
testing included a reverse group. The historical group
should have been performed in a fully automated system,
in control of the LIMS or analyser, with nomanual edits;
however, further aspects of validity should be locally
defined, with consideration given to where and when
the group was performed and recorded.
v. The risks involved with omitting the reverse group decrease
with the number of matching historical records. Where
there is only one historical record, the first sample could
have been taken from the wrong patient, and a grouping
anomaly in the subsequent sample could be overlooked
without a reverse group, e.g. mixed field reactions
(potentially indicating an ABO incompatible transfusion)
are sometimes not detected or are misinterpreted.

 

Edited by srichar3

Share this post


Link to post
Share on other sites
On 6/7/2019 at 4:58 PM, Dansket said:

Testing the same specimen twice may detect some internal testing errors, but will not detect WBIT (Wrong Blood In Tube).

You need to gather some data to show how many patients would be impacted by collecting a second blood sample. 

Ask these questions, "How many patient admits annually?", "How many patient admits required blood bank testing?" (at my facility the calculated percentage was 11%), "How many patient samples type as Group O?" (at my facility the calculated percentage was 55% and we don't draw a second blood sample on these patients), "Of the non-Group O patients, how many had an independently collected blood sample in Hematology that could be used for the second ABO blood sample" (in our facility that was calculated to be 16%).  

So for every 1000 patients admitted annually, 100 (I'm using 10% for sake of simple calculations) would require blood bank testing of whom 45 (100-55) would be non-group O, 7 (45 x 0.16) would have a blood sample in hematology, leaving  38 (45 - 7) or 3.8% (38/1000) patients requiring a second sample to be collected.  

Using this kind of data will give you a much better grasp of the impact of routine performance of a second ABO determination on all patients for whom a Type and Screen or a Type and Crossmatch is ordered.

I do not think there is any way to always avoid WBIT.  If a particular error in patient or specimen ID can be made once, it can be repeated. What a second specimen does is verify that the two specimens are the same ABO/Rh--which is good enough to avoid an ABO acute hemolytic transfusion reaction. 

Using a BB armband P&P properly will assure you that the blood you are testing and the patient it is being tested are the same--even if the patient ID is wrong.

Scott

Share this post


Link to post
Share on other sites
Posted (edited)

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

Edited by MAGNUM
added more information

Share this post


Link to post
Share on other sites

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:

  1. Testing a second current sample.

  2. Comparison with previous records.

  3. 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).

Share this post


Link to post
Share on other sites

We switched to using two samples drawn at a different time if there was no history several years ago.  I had previously worked at a place that required two signatures, but we received a WBIT from ER  with two signatures so I knew that had problems.  There were different challenges in different areas of the hospital hen we added the second specimen type. We trained labor and delivery nurses to draw and label a tube when they started the IV. We were able to use previously collected (within 24 hours) Hematology tubes and most in-patients had those.  When pre-admit patients needed a second type, we ordered the test for the morning of surgery, and called day surgery to flag the chart. The main problem was getting a second sample from ER, but getting a properly labeled sample from ER was always a problem.  I learned nursing policies at my facility were changed a lot and the nurses appreciated getting notices and being trained on the change prior to the change.  We did one type on an analyzer and a tech did a tube forward and reverse for the second type.  

Share this post


Link to post
Share on other sites

It curious that the CAP requires that the Rh type be verified by repeat testing, but the AABB requires verification of the ABO group only. Also, the two Checklist Requirements appear to contradict each other in that TRM.30575 mentions "...Verifying the ABO group of the intended recipient ..." while TRM.40670 states "The recipient's ABO group and Rh(D) type has ben verified"...

15 hours ago, sgoertzen said:

 CAP Checklist Requirements:

TRM.30575 Misidentification Risk

The facility has a system to reduce the risk of mistransfusion for non-emergent red cell transfusions.

...  (1) Verifying the ABO group of the intended recipient on a second sample collected at a separate ...

 

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.

Hopefully, the FDA will adopt the more stringent requirements of the CAP or the AABB, so that ABO verification by repeat testing of the recipient will be required of all US hospitals, not just those who are CAP/AABB accredited.

Share this post


Link to post
Share on other sites

Just wondering why most use a 2nd sample only within 24 hours of collection. Does anyone see anything wrong with testing an older sample, say 3-4 days old??

Share this post


Link to post
Share on other sites

We test any sample that meets the manufacturer's specimen requirements and ours are more than 24 hours.  We even validated citrate tubes so we could use them for blood types.

I'm comfortable with getting a second draw on only non-O patients because we also have a BB banding system and an electronic patient ID system.  The problem is the rogue humans who decide to make end runs around the systems but with belts and suspenders and duct tape, I feel pretty confident.

We are also lucky in that we do the prenatal testing for most of our OB patients.  That's a point to consider in making the determination of how many specimens you will have to collect.

Share this post


Link to post
Share on other sites

We have been doing second ABO/Rh types on transfusion candidates with no previous history since 2002! We use previously drawn hematology specimens whenever possible.  Since nursing does some of our draws, we send a small pink top tube to the floor to be used (we are the only department allowed to order and use these tubes) for the "confirm type".  We use parafilm around the cap so we can make it "tamper proof" to some extent.  Before we did this step, industrious people would draw two tubes at the same time and save one, waiting for our request of a second draw.  They would pour over the saved tube into our special tube....now they can't.  We do second types on all ABO types, we don't exclude type O.....they too can be WBIT.....which could affect other lab departments.....we let them know if we find mistypes.   We also don't exclude emergency transfusion......that is when the most errors happen because people seem to lose their minds in high stress situations.  We stick with type O until the confirm type has been drawn. 

We tried the two signatures on the tube route, but found they were just grabbing anyone and having them sign the tube whether they witnessed the draw or not.

Fun times in the blood bank! :)

 

Share this post


Link to post
Share on other sites

With a few exceptions, only Lab phlebots draw BB specimens here.  And we have our own BB armbanding system.

Scott

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now

  • Advertisement

  • Site Suggestions

    Site Feedback & Suggestions

×
×
  • Create New...

Important Information

We have placed cookies on your device to help make this website better. You can adjust your cookie settings, otherwise we'll assume you're okay to continue.