Uncrossed?

[Cathy]

Hello, I would like to ask what you would have done in a situation that I was involved in. We had a 1-2 week post op cardiac patient who had been unstable since her surgery. We were issuing IgG-crossmatch compatible red cells for a non-specific antibody without any problems. On the day in question, as a last ditch life saving measure, her chest was opened in her room to try to control bleeding. A nurse called down for blood but could not provide the patient's blood bank id number.

I knew what was happening so rather than insist or argue, I said fine but it will have to be considered uncrossmatched, inform the doctor. I pulled a crossmatched (O pos) unit off the shelf and wrote in black permanent marker "uncrossmatched" on the tag and placed an uncrossed sticker on the transfusion record, where the doctor would later sign and indicate the reason for giving uncrossed.

This created issues. The doctor felt (initially) that this contributed to her demise. Our medical director said I should not have said it was uncrossmatched because it had in fact, been crossmatched. The doctor later understood it was compatible but still insisted that we note in the chart that the blood was crossmatched. (I was later informed that the nurse crawled under the bed to verify the patient's bb id number. )

So my question is, what would you have done in this situation. Do you have policies in place for these sorts of exceptions? Use alternate form of patient id? This patient was an O, so I had no problem giving out O uncrossed. What if she was an A with an antibody? I still say no id, no crossmatch.

This happened a couple of months ago but is still nagging at me. Thanks in advance for your input.

[John C. Staley]

Morning Cathy, Does your blood issue protocol address what to do in the event required patient identification is not available? If not it should. Based on the information you provided I, for one, certainly could not fault you for your actions. It sounds as if the transfusion was not delayed to any extent. If the nurse knew that the BB Band identification was required to issue crossmatched blood then they should have crawled under the bed in the first place. I know that things go crazy in ICUs but that is the most important time to follow protocols. I cringe everytime I hear an ER or ICU nurse screaming, "We don't have time to do it right!!" They certainly don't have time to do it twice or have to treat a hemolytic transfusion rxn along with everything else. Don't beat your self up over this. I think you did fine.

[Cathy]

John, Do you have such a policy in place? Ideas that I have heard so far include using 2 alternate forms of id, like name and med rec or dob. I still have trouble accepting this, obviously the nurses would resort to it in other cases (when they can easily read it off the chart) and how are we to know whether or not it is an actual life and death situation. I knew right after the incident that this could be used as a learning experience and the procedure would need updating. The delay is agreeing on what to update it to. Thanks!

[donellda]

I think you did fine too. I am sorry you are still haunted by the incident. We have the situations where the doctors say they have no time for us to issue crossmatched blood. When we tell them they can have uncrossed as long as they sign an emergency release form they change their minds very quickly when they have to take the responsibility. We do have a John Doe policy in our ER when there is no time to identify a patient. We have pre-prepared packets with sequencial John Doe numbers and medical records. If a patient needs uncrossed blood during a trauma, they need to assign one of these IDs and come to the blood bank with an emergency release form signed by the doctor and patient labels. They are then issued O negative packed RBCs and are instructed to send a specimen as soon as possible. The patient needs to remain John Doe during his hospital stay.

[Lcsmrz]

Similar incident happened to me several months ago, with a transporter with no patient ID in her hands needed 2 units NOW on "ICU 5" where a code had just been called. I issued two O+ units on emergency issue, rather than take the time to find out who was really in ICU 5 or to send the transporter back up for an issue slip.

I had the time to follow the transporter upstairs to confirm the identity of the patient, then reverted to the already-crossmatched units for subsequent issues under process-controlled circumstances. The physician at the bedside questioned the use of uncrossmatched blood when units were on hold, but understood my situation, once the facts were known.

It's easy to be a "Monday morning quarterback" when reviewing an emergent situation, where variables become known quantities. It's also a great learning experience for everyone to review what happened, where decisions could have been better, and what questions could have been asked to clarify the situation better before responding.

Makes us all better prepared for similar situations in the future ... and you can be assured something similar will happen in the future !!

[John C. Staley]

Morning Cathy, (I always visit my websites first thing in the morning before the day gets crazy).

Our blood issue policy simply states that if the required patient identification is not available blood can not be released. If the situation is urgent then it indicates we follow the emergency release procedure for issuing uncrossmatched type O or type specific RBCs. We do not use a blood bank specific identification for patients. They wear one armband and it takes care of everything. It has two Unique Identifiers, Patient Name and Unit Record (UR#) number. The theory is that when the patient enters the systm they are assigned the UR# and it stays with them for ever. When requesting blood the nurse must provide both the patient's name and UR#, without those we go into emergency issue mode if needed.

[David Saikin]

I concur with everyone that this situation was handled appropriately. Wherever I worked and used a BBID# the policy was - no number, uncrossmatched O's . . . no exceptions. One question I would like to see addressed is "What was the patient ID doing under the bed?" The biggest problem with BB ID bands (and even hospital ID bands) is that they get cut off.

[Cathy]

The patient's arms had been draped, so I guess she had to get down to get to her arm to see the number. That is what was described to me when I asked how the two nurses could sign their names that they had identified the patient.

Thank you all.