Another question about 2nd typing patients.

[John C. Staley]

Another question has come up concerning a second ABO/Rh type on a patient prioir to transfusions. If you don't have a second type and FFP and/or platelets are requested before a second type is possible how do you respond? Type specific with the type you have or do you treat them as type unknown?

[Dawn]

We treat them as type unknown. But generally if transfusion is needed immediately the 1st tech will pass off the sample to another tech.

(If it is not a rush, the next shift performs the retype.)

[jorlin]

Historical types are used for issuing FFP, cryo or platelets in our lab.

[luhubert]

C'mon - it only takes 20 seconds to perform that 2nd type. Don't make it mandatory that it be a different person to perform the confirmatory type.

Just make sure the person starts over with the original specimen tube.

We never have enough platelets so we can't give type specific.

We do give type specific or compatible FFP, but doing the "RETYPE" just doesn't take long enough to ever be a problem.

If we don't have a specimen on the patien :roll: t, then we give AB Plasma.

[safars]

Another question has come up concerning a second ABO/Rh type on a patient prioir to transfusions. If you don't have a second type and FFP and/or platelets are requested before a second type is possible how do you respond? Type specific with the type you have or do you treat them as type unknown?

Our "second type" is on a different specimen that the original (if the patient has a historical type we accept that as the second type). Our main concern is hemolytic transfusion reactions, so we require a second type before we issue any red cell product other than O. We do honor one type for FFP and Platelets. If we have no type at all, and it is emergency release, we issue AB FFP and platelets (if AB platelets are available).

[Abdulhameed Al-Attas]

We can ONLY treat the patient as type unknown in case of first class Emergency.

You did NOT mention any emergencies and you had the first sample, all you need is to

inform them the importance of the 2nd sample and that you wont issue anything unless

the 2nd sample is provided.

You can't solve this to that.

[John C. Staley]

C'mon - it only takes 20 seconds to perform that 2nd type. Don't make it mandatory that it be a different person to perform the confirmatory type.

Just make sure the person starts over with the original specimen tube.

We never have enough platelets so we can't give type specific.

We do give type specific or compatible FFP, but doing the "RETYPE" just doesn't take long enough to ever be a problem.

If we don't have a specimen on the patien :roll: t, then we give AB Plasma.

A second type on the same sample is of no value what so ever. If you are going to required a second type any thing other than a new sample is nothing more than smoke and mirrors!!

[BSIPHERD]

A second type on the same sample is of no value what so ever. If you are going to required a second type any thing other than a new sample is nothing more than smoke and mirrors!!

I beg to differ! In the 30 years I have been in my current job, there have been 2 or 3 occasions when the wrong blood was given. Luckily, the patients suffered no long term injury. In no instance was it due to "wrong blood in tube". Due to those problems, we require a second type on the current specimen if we do not have a historical type. The second type has to be done separated in time from the first, and has to be done on a new cell suspension.

After the initial type is done, units are selected. Then (after the mind is cleared from the first type) the specimen is re-identified, a new cell suspension is made, and a second type done.

I think you have to look at your own experience of what your problems have been and determine based on that what actions will be helpful.

[John C. Staley]

Relying on your own experience is a good place to start but the extensive study literature seems to indicate otherwise. A second sample will catch both problems while re-typing the same sample, at best, does half the job and the more uncommon half at that. Granted, it is far easier and quicker to re-type the original sample but the studies indicate that this is not where the majority of the problems occur. Sorry but this is one of the few subjects where I am very unlikely to change my opinion.

But you are welcome to try.

[Mabel Adams]

I won't really try to change your mind because I think a second specimen is better too. However, the statistics on mistransfusion show that errors in the BB are not a miniscule percentage. Maybe a 20% increment of improvement is worth something--especially when retyping the sample is so easy. Of course, at our facility, we wouldn't have the luxury of a second tech to do it most of the time.

Getting that second specimen introduces some big issues for us--especially since one of our hospitals is a 15 min. drive away.

[BBK710]

I have to agree with John. While we have a second tech retype the same speicmen for patient testing that does not require transfusion we require a second specimen be tested for transfusion of any blood product when there is no historical record of type. We began doing this about a year and a half ago and it really has not been that difficult. We will use a specimen from another department in the laboratory as long as it is labeled correctly. The only problem that we have encountered is that the Emergency Deptartment tries to get around the requirement by drawing two tubes at one time and putting different times on the tubes when a second specimen is needed. Unfortunately no matter what you try to do to guarantee patient safety it seems that someone will try to find away around it.

After the recent article about the incident in Florida I am glad that we have this policy in place. It allows me to sleep at night.

[BSIPHERD]

Relying on your own experience is a good place to start but the extensive study literature seems to indicate otherwise. A second sample will catch both problems while re-typing the same sample, at best, does half the job and the more uncommon half at that. Granted, it is far easier and quicker to re-type the original sample but the studies indicate that this is not where the majority of the problems occur. Sorry but this is one of the few subjects where I am very unlikely to change my opinion.

But you are welcome to try.

I wasn't taking issue with your decision to use a second specimen, or with your logic. I was only taking issue with the comment:

"A second type on the same sample is of no value what so ever. If you are going to required a second type any thing other than a new sample is nothing more than smoke and mirrors!!"

I think saying it's of no value what so ever is not valid.

There is a price to pay for the second specimen choice - heavier workload for phlebotomy personnel (or as in at least one place where nurses collect specimens, them drawing two specimens at once, keeping one available to add a new time to if a second specimen is called for), transfusing more group O blood to non-group O patients (at least one expert thinks this is not a good thing to do medically and of course, you have less group O blood for group O patients with whatever consequences that may have), and we would charge for it. But regardless whether it's charged for or not, it adds another cost to the medical system in added workload and supplies. If you do one thing with the dollars, you can't do another.

[galvania]

After the recent article about the incident in Florida I am glad that we have this policy in place. It allows me to sleep at night.

what happened in Florida?

[jhaig]

Here we go again! The last time this issue came up it sure got some attention.

What we do as far as FFP is give AB if no current or historical type is available. Platelets, well, they'll probably get whatever is available and can get to my hospital the fastest since we don't store them in-house.

Retypes - our policy states that if a properly labeled second tube from a separate draw is available, that tube is to be used for the second type if no historical type is found. If there's no second tube available, the current specimen is re-tested using a different aliquot. I'd prefer a second draw or to issue only group O red cells until a re-draw is done. Baby steps count as long as they're forward...

[bbbirder]

This is a thorn in my side, still. Currently we are retyping the same specimen, but I want to change to a second specimen. (We use the typenex system so I think that adds a layer of security).

Like most of you, I see a 2nd specimen request creating problems for ER and Surgery patients. I am thinking of setting up a different protocol for ER and OR patients, and that is to require a 'witness' to the draw. OR should be easy, while ER could be challenging, as always.

Regarding Florida, try this link (though there are other news stories on this as well).

http://www.news4jax.com/news/15105581/detail.html

Linda Frederick

[John C. Staley]

Linda,

Some places have gone to providing only type O to OR and ER until they get a second sample. I guess that all depends on the depth of you O inventory and how often it would happen.

I've heard of more than one ER that got smart and would draw 2 samples holding one for "later" if needed. It's amazing how creative we humans can be!!! Especially if we can come up with a better way! (Better usually means easier for me.)

[Pailloz]

I do agree that 2nd draws are preferable to repeat testing on the initial specimen. Due to the tight volume restrictions placed on PEDS patients , it would be very difficult to force 2nd specimens from our patients. Any repeat collections must be approved by the MD prior.

In the absence of 2nd specimens, ER/ trauma patients with no history all get O rbcs and AB ffp.

[reidhospbb]

I will concur that having a second specimen is preferred, but in response to financial pressures we have a second tech repeat the ABO and Rh on the same tube. We have caught at least two errors because the ABO and Rh was repeated on the specimen. However, in another instance, the tech repeating the ABO and Rh used the same tube of (incorrect) blood as the first tech. If the second tech would have followed procedure, the first mistake would have been caught. Pros and cons both ways.

[Packer Banker]

We do a retype regardless of time constraints- as stated before, a retype really doesn't take too long. If another tech is available, a second tech does the retype. If not, the first tech does the retype and orders a second retype for another tech to complete at a later time.

Also related- We are an independent lab within a hospital system. We fairly recently started a policy regarding specimens drawn by non-lab employees. If a non-lab employee draws (and bands) a sample for cross-match, we do the appropriate testing and issue only type O blood when there is no type on file for that patient. This doesn't happen very often- it's most common with dialysis patients off-site.

[swede]

We do a second type on all patients without a history on file. We use specimens from a separate draw from other depts when possible. If the patient needs to be redrawn, the blood bank tech generates an order and sends a "marked" tube to the appropriate nursing unit via secure transaction in our pneumatic tube system. The tube is marked so enterprising nurses can't draw 2 specimens and hold one back. We have been doing this for 2 years now and have only had a few problems.

[BBK710]

We do a second type on all patients without a history on file. We use specimens from a separate draw from other depts when possible. If the patient needs to be redrawn, the blood bank tech generates an order and sends a "marked" tube to the appropriate nursing unit via secure transaction in our pneumatic tube system. The tube is marked so enterprising nurses can't draw 2 specimens and hold one back. We have been doing this for 2 years now and have only had a few problems.

I like the idea of a "marked" tube. How exactly do you mark them? I can see our nurses trying to remove a sticker and put it on a previously drawn tube. I am concerned that if we used a marker on the tube they would cover it up with the label.

[swede]

We mark the actual tube with different colors of highlighters. We also write our initials within the highlight line. We place the label on the tube and they are so sticky that it is obvious if anyone tried to remove it to place on a different tube. So far (2 years) it has been working.

The nurses or PCTs drawing the tube still need to sign with their ID when they draw the tube.

[Mary]

Sounds good, except prelabeled empty tubes are scary. We only allow labelling on filled tubes at the bedside.

[swede]

Yes, prelabeled tubes are somewhat scary, but it was the lesser of the evils of letting them print out their own labels and get their own tube because that is when they start drawing two at once and saving them. There is not going to be the perfect solution to drawing and redrawing. Hopefully you will be able to find something that meets the spirit of the checklist and is still safe for the patient.

We use the Mobilab barcode drawing system here, so patients are drawn with barcoded labels and armbands on the first draw. There are also ways to get around this, so nothing is 100%. Good luck!