Typing New Patients Twice

[Mary]

I would be interested in learning what others are doing when you are not using the computer crossmatch, to confirm the correct ABO&Rh type of patients that have no existing history in your computer.

Does a second tech retype from the same tube?

Do you retype all patients or only possible transfusion candidates?

[Cliff]

We are a large facility, processing about 90-100,000 samples per year.

We perform a confirm type on all samples that do not have a historical type, regardless if they are to be transfused. This includes baby samples.

[bevydawn]

At the facility that I work, we have no procedure or policy regarding re-typing new patients to confirm the ABO. Yet, whenever I receive a specimen on a patient with no history that is for crossmatch, I ALWAYS retype the patient. Once I am finished with the initial type, I throw everything away except my pink top and order a type at no charge and start from scratch. If we receive a specimen merely for a type and screen and the patient has no history, I don't bother retyping because if an order for crossmatch is received at a later time, it is our policy to retype the initial specimen before performing the initial spin crossmatches so I can rest assured that there will be 2 types performed. I have also managed to convert a few other techs to performing an 'addtype' on any new patients they receive, because I feel whether it is policy or not, it is a good practice to follow.

[adiescast]

We currently perform a second type on the same sample by the same tech. The first cell suspension must be discarded and the whole thing set up fresh. This is done on any type and screen or crossmatch order.

I am looking at the second sample route because I want to start electronic crossmatch. It is very complicated with a large number of sample coming in and a level one trauma center and active OR.

[Jane]

We also perform a second type on all patients with no historical type. I am trying to avoid the second sample for all the complexities that it will bring. We currently have lab personnel draw all samples for blood bank and use a Blood bank armband.

[Cathy]

We also perform two types on the same sample, different techs. We do this for all patients without a type in history.

[Kathy3171]

We perform two types on every patient without a history regardless of transfusion requirements. Because we are small and only have one tech in the department at a time, the same tech retypes the patient using the same sample. We use two different methods, though, because our primary typing is performed on the gel and our retype is performed by tube.

[csjuarez]

We require a second sample, drawn by a different phlebotomist, and where possible performed by a different tech! Though that may seem to be overkill, it definitely provides a good measure of safety. Even though it is a hassle, I think that it is a good policy to do the second type on a different sample since most errors in typing a patient would stem from misidentification of the patient or sample rather than the actual testing.1

[Laura]

We recently started a pilot where we require a second sample for any patient with a blood bank order who does not have a blood type in our system. We will not release blood on the patient until we have confirmed the ABO/Rh. (We do not currently have any other system, such as bar codes, etc. as a safety net for ID errors).

Prior to this pilot, we had a second tech re-type the same sample. This was primarily for computer crossmatch. It was rarely to never that we found a discrepancy.

We started the second sample requirement due to the increasing number of mislabeling errors we were seeing, especially in ER and L and D.

Second sample is not without its hassles. In looking at the preliminary data, I am not always sure if we are fixing a problem or creating more...the jury is still out. Of course, preventing even one fatal transfusion reaction makes it worthwhile.

I have no idea how many facilities around the country draw a second sample, but I am certainly interested in other people's experiences.

[Mary]

Laura,

I would be interested in what you meant by "creating more problems" with a second sample.

[reidhospbb]

We have a second tech perform the ABO and Rh on the same specimen, but they confirm the patient's id, make their own suspension, etc. We recently caught a mistake made by a new technologist. We retype only transfusion candidates that have no previous history in our system.

[John C. Staley]

I see no value in retyping the same sample and even less value if it is done by the same tech using the same reagents. In my opinion (for what it's worth) if you are going to do something then it should be on a different sample collected at a different time. This will cover more of the variables including patient identification. Even then I'm not an advocate of second typing new patients, I'm convinced it causes far more problems than it solves and has the potential of delaying much needed transfusions. If you're really concerned just give type O until there is a second type on record.

[David Saikin]

We type the same sample twice for possible transfusion candidates if there is no previous history. We toyed with the 2 specimen concept for a few weeks . . . problems we encountered were: ED pt gone somewhere else in the meantime, OR patient drawn preop now in the OR, outpatient now gone home. Yes, there are ways around all of these. I assume that everyone is hot on this wagon due to CAP 35150(?) or JCAHO recommendations . . . Bite my tongue, but, are we drawing extra specs for other lab orders (whose results may also endanger the pt's life)? I'm not talking about a redraw to confirm an unexpected or panic value result.

[ABQ bloodbanker]

We currently do a forward retype on all patients with no prior history, regardless of transfusion status. It is preferable that a second tech perform the retype on the same tube (if a second tube is unavailable), however, the retype must be done before units are issued, so if it's on an off-shift or weekend, the same tech may do their own retype, using fresh aliquots. We are thinking of requiring a second tube for our cardiac surgery patients with no prior history so we can utilize the electronic xmatch on them, getting that second draw when the IV is started before their procedure.

[sandy]

Even though we use an electronic crossmatch we REQUIRE that all transfusion recipients have a second tube drawn for an ABORh type prior to transfusion.

[Franklyn]

I work for a large institution and we go the "same sample, different tech" route for confirmation of the ABO/Rh on all new patients (including babies). We recently switched to Electronic crossmatching (Sunquest) and this practice is supported by the ElecXM process within Sunquest.

We have discussed the second sample route in the past but the screams of the nurses, surgeons and other medical types are still echoing down the hallways...

[Old Ohio Banker]

We have since the mid 90s (when phlebotomy was decentralized) maintained a policy to give all group O red cells until a second sample drawn at a different time is confirmed.

[DHarts]

I have to agree with John. You can re-type the same sample a hundred times but will still be the wrong type if the specimen is mis-labeled. I have heard the cries of doctors, nurses and the even the phlebotomists. And I know that even if two samples are the rule, they will try to sneak two drawn at the same time and initial them with different color pens to make it appear as two draws! But you should hear them stutter and stammer when I reject both specimens because they were both hemolysed to the exact same color! So much for saving time.

Dawn

[galvania]

Just out of interest - does anyone do a 'bedside test' in the states?

[bbbirder]

I'm trying to get one, comprehensive plan for both e-XM (which we can't actually do yet thanks to Meditech) and to prevent "WBIT" (wrong blood in tube).

Doesn't E-XM require that you do both forward and reverse typing?

Thanks,

Linda Frederick

[Franklyn]

Yup... The AABB (at least) requires two full forward and reverse types to qualify for E-XM. The FDA doesn't say that, per se', but I am willing to bet that they also look for it.

[BloodBank]

We are large facility and we have our own blood bank phlebotomists. We perform second ABO/Rh on patients with no history and need FFP or RBC transfusion. Second ABO/Rh will be done by another tech. but same sample.

[DFields]

Has there been a recent poll as to how many Transfusion Services are now requiring a second tube to confirm ABO/Rh for new patients?

[sgoertzen]

I am the supervisor of a transfusion service at a pediatric hospital and on Oct. 1, 2007 we adopted the 2nd required specimen (drawn at a different time) prior to issuing them red cells for transfusion for all non-O patients who are over 4 months of age and have no historical ABO/Rh on file. We do our best to find another lab specimen from a previous or subsequent lab draw to prevent the kids from being re-poked. For patients that will be getting group O red cells anyways (neonates and group O patients), we simply repeat the ABO/Rh on the same specimen if they have no history. If the 2nd collection is a "hardship", we give the MD the option to request we set the patient up on group O red cells. We are finding that we only need 2 or 3 patients redrawn per week (mainly pre-ops) with no history. Our SURG staff is great in getting us a fingerstick microtainer while they are checking in the patient for their surgery, or they wait until the patient is sedated. Since we do a recheck with a quick forward type, it doesn't take but a minute.

If we can adopt the 2nd specimen policy at a pediatric hospital... anyone can do it!

[estiner]

January 2007 we instituted the policy that for any patient without a history, we would give only type O red cells until the patient's type could be confirmed with a second specimen from a separate venipuncture (preferable by a second phlebotomist). This has worked very well with minimal impact - most of our patients have a second sample from a different venipuncture already in the Hematology dept that can be used for the confirmation blood type. Inpatients and ER patients can be drawn for the 2nd type (our doctors like the confirmation policy to verify the correct type is given). So the only patients we might have to give O red cells to are the new pre-admits. Sometimes we are even able to get a second sample prior to surgery if we are short on type O.

This is safer than our previous policy of retyping the same specimen - any errors in collection would not have been caught - as was evident in a neighboring hospital who had a collection error resulting in a patient death.

Our new policy helps prevent this situation from happening.