Typing New Patients Twice

[Eoin]

We routinely double type patients, regardless of whether they have a previous record or not (records have known to be wrong - (e.g. older records may have incorrect RhD type for instance - before current generation of monoclonals). This is performed by a second scientist wherever possible. It is always done from the primary sample tube. It is done by an alternate technique (tube if original was in gel cards).

On call, the scientist must perform a second type themselves, again sampling from the primary tube and using a second technique. This must be separated "in space and time".

[Mabel Adams]

In a few years when barcoded armbands become common, will those that have gone to typing 2 specimens go back to only one?

My hospital is already looking at barcoded armbands and we may skip the double specimen concept if it comes together soon enough. I wonder if 5 years from now double typing AND barcode armbands will be the standard of care.

The barcoded armbands will only work if there is something that stops the nurse from proceeding with the transfusion--or at least warns her/him and she trusts the system enough to heed the warning.

[Mary]

That would be wonderful. All this fuss that we are going through with bar coding (ISBT) might be worth it when the end user (nurses and docs) have bar code readers that increase patient safety. I suspect it will be expensive.

[shelleyk482]

We have required a 2nd sample for many years. We have a comment that we append to a crossmatch order that tells the nurse whether or not a 2nd sample is needed, if one is needed, the nurse knows to collect a few drops of blood in a bullet and bring it down to be tested at the same time that the product is being issued. We are a fairly large transfusion service (we issue an average of 110 products/day) so we always have 2-7 dedicated blood bank techs on duty; one is issuing while the other does a "quick type check" therefore our process doesn't delay the issue process. This requirement is applicable to both our adult and our children's hospital.

I don't intend to change back once we go to barcoding system; pharmacy implemented a barcode system a couple of years ago and we've had a continuing problem with nurses printing extra barcode identification labels and putting them on the patient's chart, carrying them in their pockets, etc rather than barcoding the band that is actually on the patient. For whatever reason, for each fix you put into place, someone will spend the time and energy to find a way to get around it

I have never quite understood the concept of typing the same sample twice. More errors occur at the patient identification level (either at specimen collection or at the time of transfusion) than at the testing level.

[huntilla]

A second tech will retype from a new tube when the patient is already an inpatient or an Er for a transfusion only (anemia/onoclogy patient). We will obtain new blood samples when necessary, otherwise we pull blood drawn within 48 hours. All pre-surgical patients with no history are a retype on the same sample with a new suspension prepared by the second tech. The intent of the CAP standard is to protect the patient receiving a routine transfusion

[VACASE]

We not only have a 2nd tech retype the sample, we also have the patient redrawn in a smaller tube (very small amount of sample) and do a front type on it. We also have an advantage, however, of looking up the patient on a national VA database. If there is an ABO/Rh on that patient in the database we don't have the patient redrawn. We still do the retyping of the original sample though.

[cmiller]

We are 115 bed hosptial and we do not perform computer crossmatches.

We perform a second type on a DIFFERENT sample for any patient for crossmatch without a history. No charge to patient.

If we have a properly labeled tube from a previous collection (within 24 hours) we will use it as the retype sample. If we do not have a tube, we order a retype ABO and have a sample collected. Our policy states that if we can't get a sample for retype before the transfusion is needed, we transfuse group O RBCs.

We have been doing this for 1 year in April and we have had very little problems with samples being collected for retypes. So far we have found no discrepancies.

As far as retyping the same tube (even when the original suspension is trashed and different techs), I find this somewhat useless for catching errors in sample collection - "wrong blood in tube".

You could retype the same sample 100 times, if it is the wrong patient's sample - you haven't helped identify a potentially fatal problem.

Hope this helps.

[jhaig]

We are 115 bed hosptial and we do not perform computer crossmatches.

We perform a second type on a DIFFERENT sample for any patient for crossmatch without a history. No charge to patient.

If we have a properly labeled tube from a previous collection (within 24 hours) we will use it as the retype sample. If we do not have a tube, we order a retype ABO and have a sample collected. Our policy states that if we can't get a sample for retype before the transfusion is needed, we transfuse group O RBCs.

QUOTE]

Stupid question time - I'm trying to get this implemented at my hospital as well. We are 295 beds and also do not perform electronic XMs. If a second sample is not available, I want to give only group O until a new specimen is drawn. When you say 'Group O' do you give only O neg or, if the patient in question is Rh Pos, would you give O pos? Do you give O Pos to males and O neg to females?

[cmiller]

QUOTE]

Stupid question time - I'm trying to get this implemented at my hospital as well. We are 295 beds and also do not perform electronic XMs. If a second sample is not available, I want to give only group O until a new specimen is drawn. When you say 'Group O' do you give only O neg or, if the patient in question is Rh Pos, would you give O pos? Do you give O Pos to males and O neg to females?

[jhaig]

I'm also more concerned about ABO mismatch than Rh. Not that Anti-D stimulation is wonderful, but Rhogam will take care of that. We also don't stock a huge amount of O neg so I couldn't just give out O neg like Halloween candy to everyone without a confirmed ABO/Rh.

Thanks for the info. My brain has gone into vapor lock today trying to complete AABB assessment material and doing an NCAA tournament bracket during lunch. :cool:

[Mabel Adams]

This is a sideline, but I think it takes a ton of RhIG to treat if you give Rh pos blood to a negative patient--and it seems to me I have read that it is not entirely effective. An interesting approach I heard for a young female inadvertantly transfused with Rh incompatible blood was to do a pheresis exchange transfusion with Rh negative blood then a Kleihauer to determine the number of RhIG doses appropriate to the remaining Rh pos cells. It worked for this one case reported. Anyone else have experience with similar cases?

That said, it is ABO that kills so I agree with the approach.

[cmiller]

This is a sideline, but I think it takes a ton of RhIG to treat if you give Rh pos blood to a negative patient--and it seems to me I have read that it is not entirely effective. An interesting approach I heard for a young female inadvertantly transfused with Rh incompatible blood was to do a pheresis exchange transfusion with Rh negative blood then a Kleihauer to determine the number of RhIG doses appropriate to the remaining Rh pos cells. It worked for this one case reported. Anyone else have experience with similar cases?

That said, it is ABO that kills so I agree with the approach.

Mabel, you do make a point about a large amount of RhoGam to cover Rh Positive RBC transfusions to an Rh Negative patient. However, instead of the 300ug doses we usually think of, we would recommend an intravenous verison. Our pharmacy has WinRho. Yes it would still take a large amount, I believe a 1500 IU of intravenous WinRho covers 15 mL of Rh positive cells, but doing this beats doing nothing.

Thanks.

[John C. Staley]

I'm curious, has any one actually ever done this? Treated an Rh pos transfusion to an Rh neg patient with massive doses of RhIG. Seems to me you would then have to treat a potentially severe transfusion reaction. Granted the hemolysis would be extravascular but there would be a considerable acceleration of RBC destruction going on. I have to wonder if it really would be better than doing nothing. Having an anti-D vs severe renal damage. Tough call.

:lonely:

[bbbirder]

John, my question exactly

... unless less than a full unit was given, I don't think I'd consider trying to give RhIG to prevent sensitization. A while back, I read the same study as Mabel mentions, about doing apheresis to remove the Rh positive cells.

Linda Frederick

[janet]

I'm curious, has any one actually ever done this? Treated an Rh pos transfusion to an Rh neg patient with massive doses of RhIG. Seems to me you would then have to treat a potentially severe transfusion reaction. Granted the hemolysis would be extravascular but there would be a considerable acceleration of RBC destruction going on. I have to wonder if it really would be better than doing nothing. Having an anti-D vs severe renal damage. Tough call.

:lonely:

Not that I've seen it done for Rh:pos cells given to an Rh:neg patient .... I have seen it more than a few times in treating ITP. Those patients we treated with massive doses of WinRho did not have anemia or signs of hemolysis develop. Cangene did send out warnings a couple years ago to watch the patient closely though!

[mda]

We reconfirm/retype all new patient in our system by a different tech.

Dennis Agricula, MT(ASCP),SBB

[lkg1972]

We retype anyone without a history using a new specimen. I believe the risk of collecting the wrong patient or mislabeling the specimen to be greater than that of the tech making an error in testing. We use a second specimen collected by a different person - it may be a specimen already in the lab in another area. We only have to recollect from the patient about 1x per day.

[estiner]

We started 1-1-07 a policy that we would not issue type specific blood until the blood type had been confirmed - this meant if we did not have a history we would look for a specimen in the lab that had been drawn at a different venipuncture. If no specimen existed, we would draw a second specimen, preferrably by a second phlebotomist so that a second person identified the patient. If that was not possible, then we only issue type O cells.

I thought this might create conflicts but amazingly, it has worked wonderfully and has the full support of the ED and nursing because we are making sure the patient is receiving compatible red cells. Rarely do we need to get that second specimen because usually we have an EDTA from a previous venipuncture - only exceptions are ED and pre-op patients. This type of policy would have prevented deaths in other hospitals in our area had they instituted this policy.

Retyping the same specimen twice does not rule out the possibility of a patient identification error, which is the most likely reason for incompatibility.

[ffriesen]

We type a second specimen drawn at a different time if a crossmatch is ordered. If the patient has had a CBC drawn at a different time than the type and crossmatch sample we can use it for the blood type recheck which we do at no cost to the patient. If no previous sample is available, we have the second specimen drawn before the blood is released for transfusion. Our medical director wanted it done that way. For elective surgeries where the type and screen is done ahead of time and no previous history exists, we send a form to the pre-op testing area to notifiy them that another specimen must be collected on the day they go to the OR.

[estiner]

My question to the latest response is why do you not charge for the second type??- it is testing done to assure compatibility just as much as a crossmatch. We charge for our second type.

[Debbie McCaskill]

After our last CAP inspection we were cited for not meeting the intent of the requirement by typing the same sample twice. Now we request a second specimen for patients that do not have a historical blood type. It is working okay but there have been some instances where we did not get that second sample. This may be a good QA monitor.

[ffriesen]

Our medical director didn't want to charge for the 2nd type on a different specimen and he felt it was more of a QA check to make sure we didn't make a mistake (Phleb collection error or tech typing error). Are places are charging for the second blood type when they are repeating the typing on the same sample?? I would think not. As many of them as we do I would like to charge for them. Can I take a poll to see how many places do charge for the second type on a new specimen???

[Angie Redd]

Our policy states that a type or identification must be verified by one of three methods. 1) patient must be verified by two different people at the time of draw and both computer sign on codes on label, patient is also banded for blood bank.

2) test a second tube that was drawn at at different time that is correctly labeled with patient name, M#, date/time of draw and person collecting initials or 3) obtain a second sample.

This is done mostly on samples collected for crossmatch and T&S, but everyone is getting used to it and doing it everytime except for outpatients.

[Likewine99]

We do a second type but on the same specimen. We do not charge for it, we consider it part of QA and regulatory. Our patients are Hollister banded, tube hand labeled at the bedside, Hollister card signed by 2 "nursing" staff members at time of collection. Or so they say!

[Winter]

Time for another stupid question! Many have said that they only issue group O if time doesn't permit a confirmation of ABO. Assuming you are not doing only computer crossmatches, do you crossmatch those O units also? Do you charge for the group specific crossmatch you did in anticipation of the confirmation tube?