Requiring two ABO's on pretransfusion patients

[Martha Fogler]

Have any of your laboratories instituted a policy to require two, separately drawn specimens for ABO/Rh before transfusion? We are thinking about requiring this in our small hospital laboratories and would like to hear about others' experiences. This policy would not require two specimens for each transfusion; once you have the first ABO/Rh on record (performed in your laboratory), the patient would only have to be drawn once for subsequent pretransfusion testing. Since these are small hospitals with only one tech on at night, we would substitute an ID confirmation by nursing personnel rather than have the night tech draw a patient twice in that situation.

Thanks.

Martha

[John C. Staley]

Just wondering why you are considering this? What is the motivation behind this direction? Are you going to be doing it for glucoses on new diabetic patients? That's no less important. On the California Blood Bank Web site there are a couple of extensive discussions on this topic and Suzanne Butch from the University of Michigan added quite a thought provoking statement a few weeks ago. I would suggest going there and reading those posts.

[luhubert]

We use an additional Blood Bank Band when a Blood Bank specimen is drawn. Since that puts up a barrier to transfusing the wrong patient. With the band in place, we only type the new patients twice from the same tube.

[luhubert]

I agree that the California e-forum is a "Great" site. Go to CBBS and you'll find it. You can sign up too. It's run by Dr. Ira Shulman, a noted transfusion medicine author.

[Martha Fogler]

Thanks, Lu, for the CBBS web site reference. I like your protocol of using the Blood Bank ID band in addition to the hospital band.

[mjegel]

I don't think it is a good idea to have different protocols on different shifts. I would think that an inspector would question this practice.

[John C. Staley]

I am very much against a Blood Bank specific armband. I am a firm believer that the simpler a process is the more likely it is to be followed. Adding an additional armband only complicates the process. Following the secnod armband logic shouldn't pharmacy have their own armband, the wrong drug can be as bad as the wrong blood? The key is having a clean, simple process where everyone involved understands the what, why, and how of it so they don't get creative. Yes, my glasses are rose colored.

[ABQ bloodbanker]

We use an additional Blood Bank Band when a Blood Bank specimen is drawn. Since that puts up a barrier to transfusing the wrong patient. With the band in place, we only type the new patients twice from the same tube.

That's what we do too! Of course, I learned from the best!

PS. Hi Lu!!

[vilma_mt]

I am very much against a Blood Bank specific armband. I am a firm believer that the simpler a process is the more likely it is to be followed. Adding an additional armband only complicates the process. Following the secnod armband logic shouldn't pharmacy have their own armband, the wrong drug can be as bad as the wrong blood? The key is having a clean, simple process where everyone involved understands the what, why, and how of it so they don't get creative. Yes, my glasses are rose colored.

I agree, I myself am not a big fan of separate armbands for blood bank. We have rejected samples because a phlebotomist mispells the name and on some occasions have accepted samples with pre-printed labels as long as the tube has a BB sticker without actually verifying what's written on the BB armband. Some nurses cut it off prematurely, some patients have 2 bands on. It's also an added expense. You'r right Pharmacy don't require a separate armband and if the hospital have a good process in place when it comes to patient identification why do we need a second armband.

I prefer to have a policy to have a second typing on patients without historical data prior to issuing blood.

All this second typing requirement is most likely from FDA's electronic crossmatch requirement. Two techs performing ABO typing or 2 samples or 2 ABO methods or 2 ABO data, to put it simply.

[LaraT23]

For those of you who do the 2 separate specimens, how do you handle outpatient surgeries? We have a preop clinic that will draw the preop labs and a blood bank tube. For many of our surgeries, the surgeons orders that blood be crossmatched the day before surgery and is ready to go. We may then get a call from surgery wanting to have the blood brought to the OR. No where in this scenario is an additional specimen drawn. We also are using an blood bank specific armband, that has an area to affix a pre-printed label (comes out when the testing is ordered) that is signed by the person drawing it that the person was identified as that person. There are several labels that printout when the order is filed, so you have another one for the tube.

[KarenJ]

We send a bright orange form to preop admitting to inform them that we need a second blood type. They get us the sample when they start the IV. So far that has worked fairly well.

[jwilb]

We type one sample twice if there is no history on file. As to armbands, how is a unique BB number assigned to the patient if not on a BB armband?

[rravkin@aol.com]

Have any of your laboratories instituted a policy to require two, separately drawn specimens for ABO/Rh before transfusion? We are thinking about requiring this in our small hospital laboratories and would like to hear about others' experiences. This policy would not require two specimens for each transfusion; once you have the first ABO/Rh on record (performed in your laboratory), the patient would only have to be drawn once for subsequent pretransfusion testing. Since these are small hospitals with only one tech on at night, we would substitute an ID confirmation by nursing personnel rather than have the night tech draw a patient twice in that situation.

Thanks.

Martha

Martha,

We require a second typing be performed on a patient with no history but we can use an other specimen from a different collection time instead of drawing a second specimen if possible. This may work better for your night shift staff.

[Joanne P. Scannell]

We use an additional Blood Bank Band when a Blood Bank specimen is drawn. Since that puts up a barrier to transfusing the wrong patient. With the band in place, we only type the new patients twice from the same tube.

Ditto.

I must add that the second ABO/Rh is a recheck using front type only AND is performed by a second tech. (ALL techs are trainable for this, no matter what department they work in!)

I don't mean to be pitting one tech against another but in addition to having the ABO/Rh confirmed, psychology has it's effects, i.e. Tech 1: No one wants to be proven wrong. Tech 2: Everyone wants to prove you wrong. Sp each is especially careful.

[Brenda K Hutson]

The 2nd draw is not just from the FDA; you will see it as one of the suggestions on the CAP checklist. And actually, having used about every system out there (red armband; no separate armband; 2nd blood draw; 1 specimen typed by 2 different Techs.; all but a barcoded armband), I have the following biases:

1. My feeling is that there is a movement towards the 2nd specimen. And when you think about it, that certainly increases the safety level over either a 2nd armband and/or 1 specimen typed by 2 people. We are planning to move in that direction next year (and my Medical Director has strong feelings about that).

2. I think a barcoded armband is also an extra safety mechanism provided it is followed through from the time of draw to the time of transfusion (and the patient has to be banded at the time of draw; not allowed to carry the armband home and bring it back).

3. I have worked in Hospitals that use the red armbands, and those that don't. I don't have a strong bias either way except to say that if you use them, I think they need to be used as intended (meaning the patient must be banded at time of draw and if they remove the band prior to transfusion, you must start over). That being said, I do have to say that I know of at least 1 time when that 2nd band (the red typenex band) saved a patient's life when the wrong patient was drawn (and the red band put on this wrong patient). When the Nurse later went to transfuse the patient, there was no red armband on them. The patient had been moved from one room to another and obviously was not properly identifed at the time of draw (it happens).

Brenda Hutson, CLS(ASCP)SBB

[crldehart]

I agree, I myself am not a big fan of separate armbands for blood bank. We have rejected samples because a phlebotomist mispells the name and on some occasions have accepted samples with pre-printed labels as long as the tube has a BB sticker without actually verifying what's written on the BB armband. Some nurses cut it off prematurely, some patients have 2 bands on. It's also an added expense. You'r right Pharmacy don't require a separate armband and if the hospital have a good process in place when it comes to patient identification why do we need a second armband.

I prefer to have a policy to have a second typing on patients without historical data prior to issuing blood.

All this second typing requirement is most likely from FDA's electronic crossmatch requirement. Two techs performing ABO typing or 2 samples or 2 ABO methods or 2 ABO data, to put it simply.

All this 2nd BT talk is from CAP transfusion med. check list.

Transfusion Medicine Checklist 06.17.2010 The previous version also included a comment that a 2nd band did not exactly meet the standard, but this has been removed.

TRM.30575 Misidentification Risk Phase I

The facility has a plan to implement 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 participate in the development of a plan to reduce these risks through implementation of a risk-reduction system.

Among options that might be considered are: (1) Documenting the ABO group of the intended

recipient on a second sample collected at a separate phlebotomy (including documentation 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.

[Joanne P. Scannell]

I believe the 'second specimen' idea is totally out of control and definitely NOT the way to security.

If we have a history of ABO/Rh from a BB Banded specimen, is that not the first specimen?

If we demand 2 specimens, what is the guarantee that the same erroneous patient isn't drawn the second time?

And you all know that nursing will find a way to circumvent our 'demands'. There is plenty of evidence to suppor this statement from 'drawing 2 specimens at the same time and holding the second tube to send to the BB later' to 'drawing the lady in the bed near the window in Room x'. We even had the wrong patient drawn and banded during a training session! Don't think that phlebotomist stationed on that floor wouldn't simple go 'redraw' that same patient when BB requests their second specimen.

Then there's the internal issues ... some collegues report that they just go into Chemistry or Hemo to find another specimen on that patient to perform a second blood type on. This is not comforting.

And what do you do if the 'second specimen' doesn't match the first specimen? A third as a tie-breaker?

Without BB Bands attached at the time of draw, who really knows who is drawn? Hospital admitting DOES make mistakes and change/update the hospital bands ... what security is that? We had a situation where the two ladies in one room were wearing identical bands. (At least with separate BB Bands, the wrong patient won't get transfused.)

So, you cannot convince me that simply '2 specimens' is a safe route.

Error potential lies in several places ... all must be addressed to form a secure process:

At phlebotomy - the patient wearing the BB Band is the patient 'in the tube' ... even through hospital ID band errors, name revisions, MR# changes, DoB changes, this fact remains the same. (And let's not forget 'Unidentified Patient' ... if you have an emergency room, you have these patients now and then.)

In the Blood Bank - processes must be in place to prevent mixups on the bench ... that includes, but not limited to, 'no transfusion until a second tech sits down and repeats the ABO/Rh on that sample'.

At Transfusion - nursing cannot transfuse unless they match the BB Band numbers. And 'No BB Band = No Transfusion'.

How about the Group O patient we had who couldn't get a transfusion of Group A RBCs because she wasn't wearing the BB Band? The lady in the next room was wearing it ... all done with proper hospital identification bands! Some patients just don't notice their bands have someone else's name on them. Without the BB Band, everything looked perfect and Ms. Group O would have recieved that Group A unit. Two specimens would not have prevented this transfusion, a 'missing' BB Band did.

Need more stories?

[lulabelle]

Many years ago, the hospital where I trained required the blood bank tech to take the blood to the patient's room to meet the nurse. At that time, she would do a finger puncture and do a slide aniti-A and anti-B. It worked very well.

lulabelle

[Brenda K Hutson]

I believe the 'second specimen' idea is totally out of control and definitely NOT the way to security.

If we have a history of ABO/Rh from a BB Banded specimen, is that not the first specimen?

If we demand 2 specimens, what is the guarantee that the same erroneous patient isn't drawn the second time?

And you all know that nursing will find a way to circumvent our 'demands'. There is plenty of evidence to suppor this statement from 'drawing 2 specimens at the same time and holding the second tube to send to the BB later' to 'drawing the lady in the bed near the window in Room x'. We even had the wrong patient drawn and banded during a training session! Don't think that phlebotomist stationed on that floor wouldn't simple go 'redraw' that same patient when BB requests their second specimen.

Then there's the internal issues ... some collegues report that they just go into Chemistry or Hemo to find another specimen on that patient to perform a second blood type on. This is not comforting.

And what do you do if the 'second specimen' doesn't match the first specimen? A third as a tie-breaker?

Without BB Bands attached at the time of draw, who really knows who is drawn? Hospital admitting DOES make mistakes and change/update the hospital bands ... what security is that? We had a situation where the two ladies in one room were wearing identical bands. (At least with separate BB Bands, the wrong patient won't get transfused.)

So, you cannot convince me that simply '2 specimens' is a safe route.

Error potential lies in several places ... all must be addressed to form a secure process:

At phlebotomy - the patient wearing the BB Band is the patient 'in the tube' ... even through hospital ID band errors, name revisions, MR# changes, DoB changes, this fact remains the same. (And let's not forget 'Unidentified Patient' ... if you have an emergency room, you have these patients now and then.)

In the Blood Bank - processes must be in place to prevent mixups on the bench ... that includes, but not limited to, 'no transfusion until a second tech sits down and repeats the ABO/Rh on that sample'.

At Transfusion - nursing cannot transfuse unless they match the BB Band numbers. And 'No BB Band = No Transfusion'.

How about the Group O patient we had who couldn't get a transfusion of Group A RBCs because she wasn't wearing the BB Band? The lady in the next room was wearing it ... all done with proper hospital identification bands! Some patients just don't notice their bands have someone else's name on them. Without the BB Band, everything looked perfect and Ms. Group O would have recieved that Group A unit. Two specimens would not have prevented this transfusion, a 'missing' BB Band did.

Need more stories?

Right; the 2nd specimen applies ONLY to patients for whom you do not have a history. The 2nd specimen is not procurred by the "same phlebotomist standing there; then sticking the patient again a few minutes later;" it is drawn at another time; often by a different person. For example, 1 well known large Medical Center I worked at used this process. For pre-op patients, the patient would come in and be drawn as an outpatient for their pre-op work. Each evening the pm shift reviewed OR schedules for the next day (also, not an uncommon process; especially in large facilities) to see whether we had a specimen and/or orders on "major" cases. They then sent a list to the OR the night before, stating which patients would need a 2nd specimen before we could issue blood. When the OR sent for blood, the transporter would come with that 2nd specimen in-hand; the Tech. would then "quickly" perform a confirmation type and then the blood was issued.

The Institution has to make it's own policies on when/how that 2nd specimen is obtained. Again, having the same phlebotomist "stand there" and draw another specimen a few minutes later is not helpful. I also do not tend to allow "sharing" of specimens between the Blood Bank and other depts. anyway (though might not object to using a Hematology specimen for the 2nd type provided it was drawn at a different time than the first; perhaps even a different phlebotomist; again, an individual Institution Policy).

After 6 Institutions (3 of them large well known Medical Centers) and 27 years of Blood Bank only, I too have many stories and I personally think that given the right protocol, the 2nd specimen makes a lot of sense.

Just my bias....

Brenda Hutson, CLS(ASCP)SBB

[rravkin@aol.com]

Brenda,

I agree that the use of a second specimen drawn at a different time is most sensible in assuring a patient's ABO/Rh type that has no prior history at the facility; I have heard many cases of how the arm bands are removed for IV's both in the patient's room and the OR; especially the OR, there the docs will remove the arm bands in a heart beat if they are in the way, and there goes your ID. I had stated earlier that I have practiced using a second specimen from a previous draw that may not have been for BB testing at all.

[Mary**]

I agree with yoou JP. Then there are always situations in smaller institutions when there is only one MT or only one phlebotomist on third shift.

[Abraham]

We confirm blood types on patients with no previous type and if patient's type is other than group O. If there is a specimen avaialble that was drawn at a different time such as Hgb/Hct or Protime etc. we use that to confirm. We only do it if patient is ordered red cells. Confirmations are not done for platelets, Type&Screens etc. Occasionally if we have problems obtaining a new sample we give group O Rh specific cells.

[Brenda K Hutson]

Brenda,

I agree that the use of a second specimen drawn at a different time is most sensible in assuring a patient's ABO/Rh type that has no prior history at the facility; I have heard many cases of how the arm bands are removed for IV's both in the patient's room and the OR; especially the OR, there the docs will remove the arm bands in a heart beat if they are in the way, and there goes your ID. I had stated earlier that I have practiced using a second specimen from a previous draw that may not have been for BB testing at all.

Where I am now (and have been for 2 1/2 years now), they do use the red typenex bands; sort of. Other places I have worked that used them, used them as intended; ALL patients being drawn for the Blood Bank (with some exceptions of course; i.e. prenatal work-up; et al) and they were banded at the time the blood was drawn. This is the first place I have worked where they are just used as an adjunct for situations in which a patient does not have a white hospital armband (specifically, patients drawn as outpatients; i.e. Outpatient Transfusions; Pre-Op). And even then, until this week, they were letting the patients carry the bands home and bring them back with them! It has taken me 2 1/2 years but I finally got the latter part changed; they are now banded when drawn. But our surgeons have already assured us that for many cases, they will cut them off; period (I asked that we devise a policy in which they immediately reapply them in a different area; but they will only agree to reapply them before the patient leaves the OR room).

We will not be moving towards putting them on all Blood Bank draws because we are instead going to move towards a 2nd blood draw and a barcode readable armband (so barcode follows from specimen and armband at time of draw; to blood product; to match of armband and blood unit for transfusion). Both of these are the recommendations on the current CAP checklist.

Brenda

[Deny Morlino]

Like Brenda we have had issues with the patient's BB ID being removed in the surgery suite. Working with surgery we attempt to place the ID band on the side opposite the surgery site. This has helped improve the process as well as having a good relationship with the anesthesia groups serving our facilities (they are normally the "culprits" removing the ID bands during surgery). Not perfect by a long shot, but better than in the past.

[Patrick Bean]

I do not like the idea of blood bank armbands. You buy a box of a 1000. Patient Jones gets BB0001. Patient Smith gets BB0002. Yes each patient gets a unique identifier but the "uniqueness" is a one character change. The advantage of a second sample is the statistical probablity of two mislabeled samples is significantly greater than the possibility someone miss reading a armband.