New question re:misidentification

[Virginia]

Has anyone had a successful CAP inspection since they added the new question TRM.30550 about misidentification of pre-transfusion samples?

We have always put a BB specific bracelet on each patient when a sample is collected and the bracelet's number goes on the sample tube along with all the usual data.

If the patient is not in our file, we have been retyping that sample with reagents from an alternate supplier, ie. Immucor vs Ortho.

The nurses then must compare the number on the BB bracelet with the same number on the unit tag before beginning the transfusion.

I wonder if our BB bracelets would satisfy CAP's reference to a "mechanical barrier". Does anyone have other suggestions, and have any been approved by CAP so far?

We have considered using the "Bloodloc" bag made by Novatek, but worry that nurses would just cut it off if they had trouble opening it. Thanks for any good thoughts.

[Eagle Eye]

Please read thread

" Confirmation of ABO/Rh"

under Hot topic. We have a long discussion going on regarding TRM 30550 & 30575.

[rcurrie]

I think you are wasting time and money by performing a retype using different reagents. That has never been prudent blood banking practice. The issue is not that you may have defective reagents (RBCs and antisera), it is that a tech may misinterpret the results or that the specimen submitted does not belong to the true patient. You do not add any value by retyping with different reagents. Also, if you will read your reagent package inserts closely, you will see that the manufacturers often use the same resources for antisera. It's kind of like going to an Exxon gas station because you think you are getting gasoline manufactured by Exxon. Gasoline refineries and jobbers have been pooling gasoline for decades. If you have a gas station owner who guarantees you that he is selling only X brand gasoline, he is either lying or highly misinformed.

Separate blood bank ID bands do NOT satisfy the "mechanical barrier" mechanism for reducing transfusion errors. I am an opponent of using separate blood bank ID bands. I do not think they add any value to the patient identification procedure. I also think it is inherently wrong to treat blood bank specimens with more importance than any other specimen. If you use special blood bank ID bands because you think that it increases the likelihood of correctly identifying a patient, then what type of ID band does your hematology department use so that they make sure the 5.0 HGB level they got really belongs to patient X and not patient Y? If you attach lesser importance to the hematology specimens, then one day patient X is going to be transfused even though their true HGB is 16.0, while patient Y, who has a 5.0 HGB, is going to suffer irreversible brain damage, have a heart attack, or die because Hematology said their HGB was 16.0. I have seen this very scenario. No special armband on either patient. Patient's Y and X have specimens drawn by the same person. Specimens are mixed. Patient X's HGB is determined by Hematology to be 5.0, but it is really patient Y's result. Here comes the phlebotomist to draw patient X for a 4 uint crossmatch. She puts a special armband on Patient X, carefully determining that Patient X is really Patient X. The blood is crossmatched, the right blood type is assigned, and Patient X receives 4 units of blood, one right after the other. Midway through the 4th unit, Patient X goes into circulatory overload. A specimen drawn when the reaction is called reveals patient X has a 21.0 HGB. A lookback at a specimen from the day before shows Patient X with a 16.0 HGB. In the meantime, patient Y codes. All this because no special attention was taken to properly match the patients to their specimens for their hematology specimens. But boy, we got that blood type right!

Those of you that are taking care of Blood Bank with no regard to the rest of the lab (or rest of the hospital, for that matter) will eventually find yourselves in the position we found ourselves in above. You have to take an "all systems" approach to patient identification: one patient ID band for all procedures, with full identification done for each procedure, whether it be the drawing of a blood bank specimen or a back rub.

BC

[bbbirder]

Bob,

Yes, all the specimens and lab results are important, but there is one significant difference between blood type results and most other lab results... there are NO clinical signs or symptoms to associate with Group O vs. Group A, etc.

LF

[rcurrie]

Bob,

Yes, all the specimens and lab results are important, but there is one significant difference between blood type results and most other lab results... there are NO clinical signs or symptoms to associate with Group O vs. Group A, etc.

LF

That is true, Linda. But blood is transfused based on Hematology results. If you treat a patient based on Hematology results from another patient's blood, you could put that patient into circulatory overload, and that can be deadly just as giving an O person type A blood can be deadly. My point is that we should not try to solve the mislabeled patient specimen from a blood bank standpoint, but from a laboratory standpoint. I have been guilty of distancing my department from the rest of the lab because we are "special." I have been guilty of thinking of that blood bank specimen as more important than any other lab specimen. But, I know longer think that it is a good idea to make a blood bank specimen more important than any other specimen. Our latest TACO, which was due to a specimen mixup, brought that message home to me.

BC

[Virginia]

I think that anyone who would not notice the difference between a spun tube of blood with a 5g Hgb and one with 16g probably should not be doing crossmatches. A discrepancy like that should always be questioned and resolved before any blood is issued, let alone 4 units.

Our separate BB bands are invaluable when patients come into ED without any identification, sometimes in groups.

It may be true that different manufacturers use the same resources for antisera. However few techs realize that, and are more likely to do that retype than if it was just a repeat with the same reagent. We usually have only one tech working in the BB, so repeat by another tech is not an option.

I agree that this does not solve the problem of patient misidentification, and am still searching for alternatives.

[John C. Staley]

I'm beginning to sound like a broken record but a second type on anything but a second sample collected at a different time is nothing more than smoke and mirrors to make someone feel like they are doing something. The primary concern is that the wrong patient is drawn and the sample mislabeled. Anything short of a second sample drawn at a different time will not address this concern. Of course the best option is to always get it right the first time.

The key to this is simple. Make sure the patient is properly identified and the person drawing the blood follows the patient identification protocol, to the letter, every, single time!!!

[Karen Olsen]

I agree that the most common error with misidentification is when the wrong patient is drawn or the tubes are mislabeled. However, rare as it it would be, there could possibly be an error in testing the correct specimen by the Technologist! Re-typing would catch those rare instances. Obviously the best solution to catch the most common of errors would be in typing a second specimen drawn at a separate time. But then there has been much discussion on how this process could be "cheated on" so we come back to the fact that everyone needs to do their job correctly! No system is fool proof. We use a BB armband more-so to be sure that nursing is giving the correct unit to the correct patient than anything else. We have two people ID the patient before the draw and document such. We have been 100% successful with this process- that we know of. We are all waiting to be able to afford the hand held electronic patient ID systems - but to be sure there will be a way for human involvment to muck that up also!

[rcurrie]

Well, Virginia, we get specimens with 16 g/dL HGB for crossmatch all the time. Some are having hips replaced, some are having quadruple bypass, some are having other procedures that can result in large blood losses. We get about 50 stat requests for crossmatch from our ER daily. None of them say "this patient is bleeding" or "this patient is going for a heart cath". In fact, none of our requests indicate whether the need for blood is concurrent with the request or whether the need is anticipated. So, I don't expect techs to question the plasma to red cell ratio. The person who issues the blood for transfusion also has no idea of the condition of the patient or the circumstances in which the blood was ordered.

I only believe in doing something when there is added value. There is no added value in doing a retype with a different mfg's reagents than the reagents used the first time. It sounds like you are trying to trick your techs into doing something rather than giving them sound reasoning as a basis for doing the retype. Also, you are setting yourself up for failure by requiring something that is not required by standards or rgulations. Suppose Joe does a type using Ortho antisera, and he gives it to Betty to retype using Gamma antisera. If Betty thinks that Joe used Gamma and thus uses Ortho, then you haven't met your own requirements, although you have met standards. However, since your tech failed to follow SOP, she is in violation of federal regulations, which require you to follow SOP religiously. Going "above and beyond" is not always sound principle.

BC

[Eagle Eye]

We have two people ID the patient before the draw and document such.

Where do you document this? DO you document thhis on specimen label?? Are your specimen label handwritten??

[donellda]

We have two people ID the patient before the draw and document such.

Where do you document this? DO you document thhis on specimen label?? Are your specimen label handwritten??

We used to have 2 people identify the patient up until about a year ago. When we did this, the person who drew the sample signed the sample and the paperwork accompanying the sample and the person who identified the patient also signed both the sample and paperwork.

[Karen Olsen]

Yes, we do hand label our specimens. Yet another reason for the 100% success rate. We document the two ID's on the requistition. We are not completely paperless - for good reason. We also still have a paper trail of the issue event. This has saved us a lot of headaches when the inventory doesn't match in the AM! It is usually because someone issued a unit but did not accept the computer screen.

[Shari]

We recently participated in an update teleconference with CAP, and they stated the blood bank armband will not satisfy the requirement for preventing errors. Although the moderator would not provide information as to what is considered as a mechanical barrier against error, it appears they are looking at barcode readers on all patients.

[Debbie McCaskill]

CAP recently had an audioconference addressing changes in the checklist. TRM .30550 and TRM .30575 were addressed. At our facility we monitor mislabeled specimens and also follow transfusions on the floor as part of our PI process to comply with TRM.30550. However, TRM. 30575 addressed the typenex armband that a lot of facilities use. This does not comply with this checklist number. It specifically says that you must have a plan in place to implement either a mechanical barrier, a second draw from the patient, or an electronic id system. Therefore, we will develop a plan to satisfy this requirement. Hope this helps.

[Karen Olsen]

Debbie,

I agree that it is pretty clear cut that TRM.30575 states that a separate BB ID band will not meet this standard. I am a little surprised that they would mandate so specifically what needs to be in place to meet this standard. Other than the separate draw which creates a lot of time constraints, excess use of type "O" RBC's, and patient dissatisfaction the options take considerable time and money to implement! We all know how hospital administrations react to those two things! Also Phase I's usually end up as Phase II's in the next cycle which will really put the pressure on! I'm all for patient safety but I'm not real happy with how quickly CAP seems to be reacting to things lately. Just my opinion.

[kelliott]

2nd sample: the decision to implement a typeck sample for non group O patients should be based on the individual facilities track record. We tried fo 8 years to train the ED, FBC and respiratory therapy blood collectors that the patient needed to be wearing an armband at the time of sample collection, that they actually needed to look at the armband and that they needed to label the tubes at the bedside. The error rate continued at the same rate so that is when we implimented the typeck system. We have been using it for nearly 2 years now and have prevented 2 mistransfusions. It works for us and we feel we have finally achieved a level of safety we are comfortable with.

As for using 2 different D reagents.... The two D reagents we use contain different anti-D producing clones. This allows us to recognize a potential D variant versus a patient with a weak D antigen. Once we detect an individual who reacts with one reagent but not the other by direct test we investigate further to see if it is prudent to label the patient as D pos or neg based on age i.e. child bearing age or not, female versus maile. Again, there is no right or wrong way ... but rather what works for your transfusion service.

[bbbirder]

I love it when technology is supposed to fix what are ususally people problems. There will always be ways to work-around any technology.

There must be these work-arounds due to down times, problems with the technology, etc. So since you must allow an alternative for those times, it can never be the one and only way to do something.

Also, nurses are very creative at figuring out ways to keep doing what they always did (perhaps incorrectly) and avoiding the technology fix.

I agree that transfusion services cannot fix these problems, it needs to come from the top levels.

[jhaig]

How many hospitals out there are going to spend hundreds of thousands of dollars to implement a mechanical barrier system just because CAP says so? If it comes down to a question of money, I think we all know how that's going to end up. CAP can't even give any clear information as to what 'mechanical barrier' they want us to implement anyway. They only want us to work on a system that minimizes patient risk.

I'm in the process of developing such a plan which will help me sleep at night.

I am leaning toward performing a retype on a second draw if there is no patient history available in the computer. On the night shift where there is only one tech, the tech can only issue group O products until a second draw, such as the morning CBC, can be obtained. Many times a CBC is ordered before the blood bank work is needed. As long as both specimens are labeled properly, this should be satisfactory. In the end, it will amount to a few more minutes to confirm the blood type and stocking more group O products. We also use a separate blood bank wristband for all transfusions. We're still working out the kinks, but hopefully this will be a huge step taken to prevent a possible mistransfusion.

I'm much more concerned about whether or not the correct patient has been drawn rather than if the tech has performed the ABO/Rh correctly. Performing an ABO in blood bank is kind of like breathing - it should be done without thinking. If a tech has a problem performing this simple task, then they should reconsider their career path.

[cmiller]

Hello Everyone!

I have just finished working on our solution to this question...

We are going to require a patient retype on all patients for Red Cell transfusions if we do not have a previous type on file. This will be for EVERY patient, including ED patients, unless it is a situation that requires Emergency Release of O Neg units.

We will accept capillary/finger stick samples in EDTA for the retype. If a sample for retype can not be collected, we will transfuse group O units, until the retype can be performed and the patient ABO Group is confirmed.

Also, if a correctly labeled EDTA sample is available in the lab, from a previous draw, we will use that sample. If a sample is not available, the patient will be redrawn either by venipuncture or finger stick.

The retype will not be on the patient chart, it will stay internal to our BB computer system and there will be no charge to the patient for the test.

We also use a separate BB Band that goes on the patient and sample at time of collection for our Type/Screens. The nurses are required to check this number at issue and transfusion. We will continue to use this banding system.

For us, this was the "easiest" and cheapest solution. We will not have the funds to purchase a barcode identification or other mechanical barrier system. And for most cases, we will have a sample in the lab we can use, so patient re-sticks should be minimal and when it comes down to it---if being stuck again could save their life, it is well worth it.

[rcurrie]

I have suggested that we transfuse O cells until we have a retype at my institution, but was voted down by the rest of the blood center administration. I am going to keep trying to institute that policy, as it is one good way of preventing the transfusion of ABO incompatible blood that not even a nurse can mess up.

As far as breathing and ABO typing, I used to think the same thing- if you can't perform a simple ABO correctly, you have no business in the blood bank. However, humans being humans, we all make mistakes, and it is just a matter of time before each and every tech who performs ABO testing will misinterpret their results. Even the best breathers have apnea on occasion. That is why I finally came to accept the policy of doing a retype by a different tech for new patients.

BC

[donellda]

We simply do not issue blood until we have 2 typings done by 2 different technologists if we have no previous history.

[Mabel Adams]

For those that are borrowing a hematology tube: do you just spin it down and ruin it for the add-on retic or WSR, or do you pour part of it off into another tube to spin down?

[John C. Staley]

Mabel, I'll take it and spin it. If they get an add on they can re-draw the patient.

[rcurrie]

Same as John. That ESR requires a freshly drawn specimen anyway.

BC

[Cathy]

In your expert opinion(s), does using the secure transaction feature on the pneumatic tube system cover the mechanical barrier question? The blood will not drop at the receiving station until someone types in the same 4 digit code that we put in when we send it. We use the last 4 digits from the blood bank id band. (I know everyone is not a fan of special bb bands. Before we started using them, we used the last 4 digits of the medical record number).

In the mean time, I think I am going to start a tally of how many times patients would have to be redrawn for the second type, versus pulling a sample with a different collection time.

Thanks!