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At my clinic, in cases where the first drawn tube on a no hx patient was not properly electronically collected, then a second sample is required. We use Sunquest and Collection Manager to track that. Oftentimes, the nurses and phlebs tend to argue why a second sample is needed, so they don't really know ahead of time to draw two tubes and stealthily send the second tube later.

I'm not sure the workflow of the phlebs and their side of the software and whether they ID the patient at the time of electronic entry and draw. However, when you cannot verify confidently that a sample was collected and verified by a tech at the time of draw, a second sample is ordered and sent at a later time.

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Here is another question to add to the mix.  Our computer system (Cerner) will auto order an ABO confirmation WHEN the first specimen is received in the lab, if there is no previous history.  We will then either send the phlebotomist to collect the second specimen or, if patient is on a nurse collect floor, send the label to the floor for collection.   If we receive a call asking if a second specimen is going to be needed, we tell them we don't know (even though we do) because we want a new, independently identified specimen.  We will not give type specific blood products until both specimens have been resulted.

OR would like special dispensation to collect 2 specimens at one time so that one can be used for a confirmation.  They feel that they are a controlled enough environment that errors should not occur and they are usually drawing in a crisis situation and cannot wait to get the order to draw the second specimen.  We would not deny them emergency blood, just type specific.  What do other facilities, that require two specimens, do in the cases of emergent (or not) situations in the OR?

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2 hours ago, pbaker said:

Here is another question to add to the mix.  Our computer system (Cerner) will auto order an ABO confirmation WHEN the first specimen is received in the lab, if there is no previous history.  We will then either send the phlebotomist to collect the second specimen or, if patient is on a nurse collect floor, send the label to the floor for collection.   If we receive a call asking if a second specimen is going to be needed, we tell them we don't know (even though we do) because we want a new, independently identified specimen.  We will not give type specific blood products until both specimens have been resulted.

OR would like special dispensation to collect 2 specimens at one time so that one can be used for a confirmation.  They feel that they are a controlled enough environment that errors should not occur and they are usually drawing in a crisis situation and cannot wait to get the order to draw the second specimen.  We would not deny them emergency blood, just type specific.  What do other facilities, that require two specimens, do in the cases of emergent (or not) situations in the OR?

We started doing reports for each time an electronic collection was not performed correctly, and it's significantly reduced these errors. As far as requesting a necessary 2nd specimen, we tend to call the floor/OR once the first test/specimen is resulted (especially in cases when the pt needs blood). So to respond to your question, I'd call them if a 2nd is needed, or they may just start sending two tubes at a time. If the OR cannot draw it through your collection system right the first time, you'd really just need two tubes drawn at two different times -- the tubes cannot have the same time listed on the label. Whether they draw it two minutes apart is their issue, and it doesn't avoid the WBIT... whether they're "controlled" or not, they're still human and human errors can occur.

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On ‎6‎/‎14‎/‎2019 at 9:48 AM, swede said:

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! :)

 

We also send small pink top tubes for 2nd types to help prevent the extra tube in the pocket.  Because we don't do it for group O patients, our number of redraws is pretty small which I think might help reduce the likelihood of holding back a second tube to send later.  We haven't been parafilming the tubes but we did pretty thorough education when we went live with this.  I hope that gets passed down to new hires.

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We also got push back on redrawing patients for a second specimen - reason...patient satisfaction. We do type one specimen twice, but use electronic patient identification and issue blood with a barrier (FinalCheck armband/lock system). I was questioned about the expense of the FinalCheck system by the hospital administrator when I proposed it, but when I told him that a second draw would be required w/o it and that the lock would be a good deterrent to hanging the wrong unit on the wrong patient IF we strongly policed the use of the system, he agreed to the expense. Is it possible to cheat the system and still have WBIT and mistransfusion? Yes, human nature being what it is, someone will always find a way around all rules, but I think it drastically reduces the possibility. I should note that we are all lab draw or lab observed draw w/ rare exceptions in the OR. That does make the armband use more effective.

I think that the 2nd person verification for patient ID at time of draw is pretty open for potential abuse.

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We use a separate BB wristband, perform electronic crossmatch, and require a second draw on patients for whom we have no type history. (We may also use a separate draw, ie. CBC if available).  Last year, a patient was registered incorrectly (same name, different date of birth - so all bands, charts and labels were incorrect). It was caught by the phlebotomist performing that second draw. If I had ever questioned our process, I certainly did not look back after that near miss. We have to remember that patient identification IS the number one safety goal, because everything stems from that.

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6 hours ago, Jennifer Castle said:

We use a separate BB wristband, perform electronic crossmatch, and require a second draw on patients for whom we have no type history. (We may also use a separate draw, ie. CBC if available).  Last year, a patient was registered incorrectly (same name, different date of birth - so all bands, charts and labels were incorrect). It was caught by the phlebotomist performing that second draw. If I had ever questioned our process, I certainly did not look back after that near miss. We have to remember that patient identification IS the number one safety goal, because everything stems from that.

In your case, all scanning would be correct so the technology won't save you.  Thank heavens for phlebs also asking patient to verify ID.  I've seen several registration errors that could have had negative downstream effects.

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17 hours ago, Mabel Adams said:

In your case, all scanning would be correct so the technology won't save you.  Thank heavens for phlebs also asking patient to verify ID.  I've seen several registration errors that could have had negative downstream effects.

With a BB armband system, the blood drawn at the time the armband is applied is going to have the same BB ID as the unit being transfused.  Even if the patient is initially registered mistakenly with another persons ID, they will be getting safe transfusions as long as the BB armbanding system is used appropriately.  (In such a case, no matter how many draws you do for the ABO/Rh, they will all be wrong for that registered name--but at least the transfusions would be safe for the mystery patient.)

Scott

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3 hours ago, SMILLER said:

With a BB armband system, the blood drawn at the time the armband is applied is going to have the same BB ID as the unit being transfused.  Even if the patient is initially registered mistakenly with another persons ID, they will be getting safe transfusions as long as the BB armbanding system is used appropriately.  (In such a case, no matter how many draws you do for the ABO/Rh, they will all be wrong for that registered name--but at least the transfusions would be safe for the mystery patient.)

Scott

God help the registered patient if he/she needs a transfusion.

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We use the 2nd person to identify, knowing full well that it is not very reliable.  We recently had a safety fair, prior to TJC arriving, and used an armbanded model as our patient and laid the collected specimen next to it.  The names were similar, but different, MRN were different and DOB was similar but different.  Only about 50% of the nursing staff caught the discrepancy.  We then explained to them that the specimen was labeled properly only from the wrong patient.  Since blood bank does not see the patient or the armbands (we use a BB armband), we would have accepted the specimen and resulted the testing for the wrong patient.  Some understood and were scared, some just wanted the stamp on their paper to get their CEUs.

Please don't ever put me in the hospital!!!

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1 hour ago, Malcolm Needs said:

God help the registered patient if he/she needs a transfusion.

I am not explaining myself well.  Perhaps it may be hard to understand unless you have used such a system. 

In a transfusion service, like a hospital, the BB armband number (regardless of the name or other information on the label) is placed on the specimen when it is drawn.  That number goes into the BB computer system when the type and screen and other testing is done.  If a product is ordered, that BB number is on the tag on the unit.  When it is issued from the blood bank, that number must be on the request form brought to the BB--otherwise no issue no matter what information matches up.  (Of course, name, birthdate, etc. must match also.)  When the unit reaches the patient, the BB number on the unit tag must match the BB number on the BB armband which is on the patient.  Its a full-circle kinda thing.  The unit is very unlikely going to go to the wrong patient--no matter how they are otherwise ID'd--if a strict BB number and armband system is used.

With such a system, which is relatively common I think, the patient can come in and be under a false ID, and still get appropriately matched blood products.  One cannot say this for a system that only depends on two separate draws for assurance that an electronic XM is appropriate.  If the wrong patient is drawn once for some reason resulting in WBIT (like in the wrong bed in a room)--the same circumstances can cause the second draw to be WBIT.  Then if the unit goes to another patient---well, that's when the God Help us comes in!

Scott

 

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Our organization fought us on this but it has been so beneficial  for patient safety. Once you implement and get use to it it’s hard to imagine going back to the old way of not confirming the blood type.  It is a struggle to get everyone on board. We still have doctors fight us. 

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I once had a patient who did not show the same blood type as his historical record.  We had to redraw him and repeat all testing which matched what we had on the sample from earlier that day.  As Scott said, we could at least safely transfuse him but later we learned that he was registered under the record of a prior patient with the same name (different DOB) so then we had to separate all of the testing records from the prior patient and clean up the records.  Much better than a mistransfusion but still not optimum.  Nowadays the habit of asking the patient to verify ID verbally should have caught that before he even got his blood drawn but this was eons ago.

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7 hours ago, Mabel Adams said:

Nowadays the habit of asking the patient to verify ID verbally should have caught that before he even got his blood drawn but this was eons ago.

This is true Mabel, but it is far from fail-safe.

We have had numerous cases in the UK (where treatment under the NHS is free) of identity theft, where a person not entitled to free treatment has come in to hospital having learned all the details of a person who is entitled to free treatment, and we have detected the fraud by them having different ABO groups and/or D types to the person entitled to treatment, or no longer have an antibody that normally remains in the circulation for decades.

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On 9/5/2019 at 10:18 AM, SMILLER said:

With such a system, which is relatively common I think, the patient can come in and be under a false ID, and still get appropriately matched blood products.  One cannot say this for a system that only depends on two separate draws for assurance that an electronic XM is appropriate.  If the wrong patient is drawn once for some reason resulting in WBIT (like in the wrong bed in a room)--the same circumstances can cause the second draw to be WBIT.  Then if the unit goes to another patient---well, that's when the God Help us comes in!

Scott

 

We also require that when second venipuncture is done, that the BB number is affixed to or written on the draw tube container label for ABO verification.  On receipt of specimen container in BB, the number is entered into the BB computer (same screen as used to enter 2nd ABO verification test results) and computer- compared (custom code in Meditech) to the number on the original specimen used for the Type and Screen.

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