Confirmation of ABO/Rh Type

[BSIPHERD]

It's hard (probably impossible) to come by absolute guarantees and perfection in life. For just about any process, someone can figure out how to get around it. I think you have to be aware of the types of errors in your institution and work toward improving those.

The perfect should not be the enemy of the good.

[Mabel Adams]

If we only have to do this in "non-emergent" cases how are we defiining this? Are all stats emergent?

I believe from the debate about computer crossmatches, it was established that we can charge for the second blood type, right?

Seems like it will be time-consuming to verify that the techs are actually doing the second type on all patients without historic types and non-emergencies (and AB Pos ladies over 104 years old with red hair...or whatever else CAP dreams up).

[rcurrie]

The new CAP checklist questions are knee-jerk reactions to industry-wide problems. You can't legislate perfection. As much as I hate cliche usage, I agree that you have to institute a culture of change. I still see nurses coming right out of school with no idea how to label a specimen. I do nursing orientation, and I see every nurse that walks in the door (about 100 new ones a month). They are astounded that they are expected to label the specimens at bedside rather than handing unlabeled specimens to the unit clerk to label.

Also, any standard that doesn't apply in emergent situations is a worthless piece of crap (I toned what I really think down somewhat). That is when errors are most likely to happen. We had two mistransfusion errors in one week that happened because the nurses involved didn't have time to follow identification procedures. Two separate patients got someone else's blood. Two units each. But, it was an emergency! We didn't have time to follow the rules! They have time now- they are no longer with us.

Years ago, when hospital administrators decided to use nurses to do everything, I knew then that this is where the industry was headed. Whenever you add responsibilities to a job that is already overloaded, the persons involved will develop shortcuts. Many of those shortcuts can lead to terrible results. Nurse drawn specimens are, in my book, "guilty until proven innocent." I don't trust a single one.

BC

[jhaig]

If we only have to do this in "non-emergent" cases how are we defiining this? Are all stats emergent?

I believe from the debate about computer crossmatches, it was established that we can charge for the second blood type, right?

Seems like it will be time-consuming to verify that the techs are actually doing the second type on all patients without historic types and non-emergencies (and AB Pos ladies over 104 years old with red hair...or whatever else CAP dreams up).

On behalf of all AB Pos ladies over 104 years old with red hair, we would be honored if CAP thought enough of us to legislate our transfusion needs:D

We do charge for the second blood type. In fact, the blood cannot be released without a confirmatory ABO in the absence of a previous blood type record.

Now about the B Neg men with no hair at all...:cool:

[sarahk]

CAP briefly discussed this in their audioconference today. Currently, just a plan of some sort to eventually implement something is required...though I believe that the moderator said that having a system in place would be required in the near future (he said maybe 18 months.)

During the question and answer section, one caller asked if CAP had any documentation to prove that a second sample or barcoding was any safer than a separate banding system. The moderator said he "assumed" the transfusion medicine committee did, but did not have any references. I would sure like to see them if they do, but I'm not holding my breath.

Our time would be better spend educating and enforcing our current policies, whether it is a separate blood bank banding system or just good ol' stringent patient identification standards. Maybe CAP needs to spend some time in the real world before they legislate impractical regulations that don't address the root cause of the problem. Thanks, I feel better now!

[rcurrie]

I agree, Sarah. We don't need another weight around our neck.

BC

[Mabel Adams]

Did the audioconference touch on any ways to meet this requirement without doing 2 blood types on separate specimens or adding a high tech or barrier system?

In other words if you have a good system--even if that is only that your phlebs do a consistently good job--so that you can give some evidence of a sufficiently low error rate will they accept that?

[yiams]

Okay, I WILL wade through all of the posts. We've been grappling with this as well. We are NOT in favor of a second draw. Is there not a CAP requirement or suggestion to try to limit the drawing of "extra" blood? The old "rainbow set of tubes" psychology. At this point we're leaning towards two ABORh typings from one sample but using different methodologies. A tube ABORh and a gel ABORh for instance. But that's why I checked in today to see a few other opinions and forward them to our BB supervisor. Maybe we WILL have to have two draws? I hope not.

[sarahk]

I love the idea of a second draw. What do you tell the patient when they ask why they're being stuck again...well, we're not sure we did it right the first time? So sorry to wake you up again and stick you for the 12th time today, but CAP says we have to, despite the multitude of processes we have in place to prevent errors.

No the audioconference didn't give any suggestions. They seem really stuck on this whole thing, so I'm not sure how much leeway they'll give. Maybe they'll just fork over the millions of dollars and hours it takes to implement a bedside barcoding system or maybe they'll cough up a few extra phlebotomists so we can meet their requirement.:mad: Ha!

[rcurrie]

Just remember, Sarah, there is no such requirement for a second draw at this point.

BC

[MJDrew]

Why do you think we are getting this "legislation" from CAP?? Is is possible that some of the "legislators" who helped to wreak havoc at the AABB, making the inspection checklists longer than most religious texts, are now finished there and have overrun the CAP??

Just a wild thought. I have been trying to "break into" the CAP Transfusion Practices committee for a number of years and have been unsuccessful, due, I believe, largely to the fact that those with "contrarian" opinions need not apply. I had some "interesting" conversations awhile back with several committee members regarding their decision to require bacterial testing of platelets when there is still no validatable method out there for RDPs outside of surrogate chemistry or pH determinations. I had argued that it ought to remain a Phase 1 until a decent method was FDA approved. At that point, the CAP standard was a Phase 1 deficiency, but now it is a Phase 2, as promised. Never mind we waste money and time with a lousy method, now it's written into "law"! If it were up to me, I'd take the Phase 2 deficiencies ad nauseum until we had an acceptable method for testing RDPs.

Sorry to change the focus of the discussion, but this is just another example of the "we know better what's best for patients" mentality I've seen going on at both CAP & AABB for some time.

Back to our regularly scheduled programming!

MJ

:cool:

[bmarotto]

I seems like they are asking the Blood Bank to solve a problem that is in most cases external to the Blood Bank. I believe there is an underlying motive behind this CAP question. Most facilities will implement the second draw causing complaints from patients, nurses, and physicians. This in turn will speed up the process of implementing bedside scanning. If Blood Banks were the ones requesting administration to come up with the funds for bedside scanning, little would be done. Complaints from other medical staff and patients will move bedsise scanning up the priority list.

I find this rather annoying. If bedside scanning is what the powers that be want, then say so and give us a deadline to comply. I bet once we all implement a barrier or second draw system that is exactly what will happen.

[bevydawn]

We do use a bedside identification system at my facility. However, only laboratory personnel are trained to use it. Nursing draws patients with ports and our Oncology patients are almost always drawn by the nurse whether they have a port or not because our Cancer Center is an off-site facility. Therefore, our bedside identification system is not 100%. I imagine it would be hard even if nursing was trained to use it as there is frequently issues with connectivity throughout different areas of the hospital as well as other computer type problems encountered on a pretty frequent basis. There is nothing that is going to be a perfect answer to this issue for all hospitals.

[rcurrie]

Keep trying, MJ. I analyze each checklist question/standard/whatever-they-call-it for logical relevancy, and fail to find it in some of the standards. Interestingly enough, I am able to link these illogical requirements to new inventions that are highly promoted as the savior for patient safety. It's all about money.

BC

[John C. Staley]

Bottom line folks, no system is fool proof. Too many fools out there. Compilcating a system does not make it better. Everytime you add a layer to checks and balances you give the previous layers less reason to be concerned because "some one else with catch it". Bed side identification only works at the bed side when the process if followed whether it is barcode or eye readable. If the identifying devise is not attached firmly to the patient it is of no value. The most dangerous person in the medical world is a patient care individual with a pair of scissors and a desire to use them. All that is happening is someone is attempting to create the illusion of caring and doing something about it. Even Bob's RFI chip in the the right eyebrow will have creative people find ways around it if they don't understand, accept, or buy into the need for "doing it right". In the words of my favorite ER nurse; "We don't have time to do it right!!!!"

[Old Ohio Banker]

10 years ago our phlebotomy moved to nursing. Our medical director at the time decided she would insist all patients receive group-O red cells until a second type (drawn a different time) was done. Luckily we are a pediatric facility and use alot of group O red cells and have been able to do this. I was shocked at this requirement when I first started here, but it works ok. We have many O units left from neonatal and ECMO reserves so it works ok for us.

I agree with all the posters. CAP/AABB need to get into the real world!

[Ellen Zeigler]

CAP Has a new Phase I checklist question, TRM .30575, for now it requires a plan, but it will move to requiring a system... There are additional references on the checklist

TRM.30575 Phase I

Does the laboratory have 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 develop 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. The laboratory may utilize any one or more of the above systems, or another approach capable of reducing the risk of mistransfusion. The laboratory should monitor the effectiveness of the system that it implements.

[rcurrie]

Ellen, you might want to go back and read the first 4 pages of this thread ;-)

BC

[caj1018]

I believe that the new CAP requirement is trying to address a patient identification issue - and is a separate issue from electronic crossmatches. We use Meditech and do not do electronic crossmatches cuz meditech just seems to have trouble with this.

One way to meet the new requirement - and what I believe is strongly recommended by CAP is to require that TWO different types be performed on TWO different samples drawn at TWO different times. The good news is that this for those patients that do not already have a blood type hsitory in the computer or manual records and are blood groups other than group O. The same tech can do both types. One way to do this is to find a CBC sample drawn at a different time on that patient and use that sample for your confirmatiory type.

We are currently trying to set this up - but having trouble setting this up in the Meditech computer so that we are 100% in compliance.

We just finished our CAP self inspection and need to get this done ASAP. If anyone has ideas on how we can get this to work in Meditech, I'd sure love to here from you.

pss - i missed reading pages 2-4 before posting. So sorry for beating a dead horse. Would still like meditech suggestions however!

[jhaig]

I'm also trying to change my retype procedure and also use Meditech. I also want to use a previously drawn specimen for the second type on patients with no previous history. How would you handle a patient arriving in the ER that has no prior blood bank history? Would you perform a second draw immediately? I would like to avoid a re-draw, so in cases like this I'm considering issuing only group O products to non-group O patients with no blood bank histories until a second specimen (such as the morning bloodwork) can be drawn. I'm not against doing a second draw, however. The inconvenience versus getting the right patient drawn is worth it in the end.

As far as Meditech, we created a reflex test for a repeat ABO only on patients that do no have a previous blood type on file.

[kate murphy]

Interesting thread - I agree with most! Particulary following the rules especially in emergencies!

It seems to me that the intent of the CAP question is that we test the right blood from the right patient - or as Sonny Dzik would say - "No WBIT!" (wrong blood in tube). Retyping the same blood in the same tube can still give you the wrong ABO.

I personally fail to see what the difference is between a separate BB armband and the barrier method. As some previous posts have pointed out, I don't trust a nurse - particularly faced with a plastic bag when they have pair of scissors.

We too have a multi-discpl team working on mislabeling errors and have shown great strides. Looking at the CAP question, our team suggested (and we are implementing) a double check at time of draw. The same approach as at transfusion. So our BB specs will have 2 signatures on them. Like many people, our night shift is one person. The BB is not close to any other labs, so no crosstraining to do ABOs.

I believe that this method will make transfusion safer, which (I hope) is the intent of CAP.

[lef5501]

Because of the incorrectly labeled(WBIT) samples we were getting from RN draws, our director figured it would be safer to only allow the phlebotomists to stick for BB samples. For any line draw, etc where a RN would be getting a sample, a phleb must be present. We do not accept any RN draws for BB. I never really like this process, but it came down from higher up. Just last week, we proved how even having two sets of initials on the tube does not necessarily mean we have a correctly labeled sample. I received a sample with the RN initials and a phlebs initials and the wrong unique BB #. So having two sets of intials on a tube doesn't always mean anything either.

[rcurrie]

There are a few different factors that come into play to explain the increasing number of errors we seem to have. Many can be traced back to management's desire to increase productivity. Some of you know that I was a locomotive engineer in my first career. In the mid-70s, the railroads hired "proficiency" experts to observe us as we worked and make suggestions to increase productivity, as if observing someone with years and years of experience for a couple of weeks, knowing nothing about railroading, could lead to good suggestions. I felt it was my job to give the "expert" that rode with me in my engine for 14 days some "good" ideas to take back to management, so, every time I needed to reverse the direction of my locomotive, which was about 30 times an hour since I was working on a yard switcher job at the time, I stopped, went out the back door of my engine, crossed around to the fireman's side, opened an electrical cabinet access door, and reversed the engine manually using the electrical relays rather than simply moving the reverse lever on my control stand. That took about 2-3 minutes each time. My ploy worked, because after 14 days of watching every move I made, the expert made one single recommendation: put some kind of switch or lever inside the locomotive cab so the engineer could reverse the engine without going outside. We called the railroads' efforts to increase our efficiency the more-for-less policy. They increased the amount of work we had to perform on each train, yet didn't give us more people to do the work. We had more accidents and more complaints. This is why I retired early after 21 years- I no longer felt safe running 70 mph 2-mile long freight trains on the same track as engineers who were exhausted to the point that they would sleep at the throttle despite all attempts to stay awake. I lost over a dozen fellow railroaders in head-on collisions due to sleep deprivation. The hospitals have done the same thing. The nurses of today have to do more tasks than ever. Efficiency and productivity can only be increased to a certain point without sacrificing quality and safety. That point has long passed in healthcare.

BC

[teskridge]

I'm assuming that the computer module that is required is the "education" portion of your plan. What is the "reporting" and "corrective action" part? What is done for each individual mislabeled specimen--phlebotomist, nurse, etc. counseled? documented in a database?

Reporting part?----report to the transfusion committee? QA team?

Just interested. I really like this idea.

[teskridge]

This is in response to jcurrie plan of action.......