Qestion authority??

[lioness@50]

My question is basic and simple. Details of this particular incident are not. I will attempt to keep it short. I came on shift (3rd) with nothing documented concerning this patient who had come in with a 5.2 hgb and with multiple antibodies, and had gotten up to an 8.4 hgb at this point. More blood was ordered at 6:50am. Antigen neg units rec'd from the Ref Lab were incompatible. The patient was drawn again and sent to our Ref Lab. At this point, it is 10:30pm. Nothing had been documented by us as far as telling the floor, calls to ref lab, ETA of second set of units from Ref Lab, etc. We (lab) screwed up. I get a call from the Nurse Supervisor wanting to know why it was taking so long and when exactly the floor could expect blood. I told her that the Ref Lab told me that this spec had not been ordered stat, and that it was ok'd to be worked up on 1st shift. I relayed this to the Sup. She was furious. She had an order to give blood. I asked what I could do to help. She asked me to call in a Ref tech (at 4:30am, now..almost 24hrs from original order time). I obliged. Because of my actions, I was told that I am not to offer to do anything in a case like this, and that it's BB "policy" to tell the Nurse Sup or Phys to take a hike, and that I have the final authority on who gets what blood. Of course, I asked to see this "policy", and it's not on paper. I'm having issues with this whole scenario, and I'm having doubts about this whole "not on paper" policies thing. I have never, nor will I ever defy authority. Am I right or wrong?? This whole incident spurred an internal report made by the Nurse Sup, but because she had no right to bug me about this, SHE was written up! WE didn't document anything. WE told the Ref Lab that because the patient had an 8.4 hgb, it could wait unitl morning. WE are not doctors. WE are not the primary care giver of patients. What's your opinion on this??

[donellda]

In our lab if it's not on paper or electronic, it does not exist. I'm learning very quickly that documentation is one of the most important things. We have a communication log where things such as this are written and passed on to the next shift. It is then their responsibility to read and sign off.

We have a similar thing happening right now at our hospital. We have a patient with Anti-U and, of course, we depend on the reference lab to find units for us. Our patient had a hemoglobin of 8.4 and 2 units were ordered. I contacted the floor because of the blood rarity to see if the patient really needed the units. We were told that the patient was going to OR the next for a splenectomy so I contacted reference lab for 1 unit. (We actually had one U negative unit in our inventory). They had a liquid unit but they did not want to give it to us unless it was going to transfused. I contacted our Blood Bank pathologist who called the surgeon. At that point the surgeon said she wanted 4 units which means deglycing frozen units. We managed to get the one liquid from ARC and asked them if their would be a possibility of getting frozen. The surgeon in the meantime, said that having 2 available was fine. The patient received her units but she went into cardiac arrest and the surgery was postponed until Friday. Again they wanted 2. We got 1 liquid and 1 deglyced and both were given and the surgery cancelled again. Now we are looking forward to the fact that the patient still needs her splenectomy as well as a mitral valve replacement. This week will be interesting.

As for your situation, we are not physicians and we can only do what we can do if we are at the hands of the reference lab. If we have difficulty getting blood from reference I make sure that the pathologist talks to the doctors involved. It shows that we are not taking this kind of stuff into our own hands. If the case is that there is nothing in writing of a policy, I would definitely pass it on to a medical director for decision making.

[bmarotto]

It sounds like there is an adversarial relationship between the Blood Bank and nursing and you got caught in the middle. If the patient was stable with a hgb of 8.4, I think it reasonable that the sample not be ordered stat IF the patient was clinically stable. This decision should have been made by a Blood Bank physician. No doubt the nurse had an order to transfuse blood, but was there a change in the patient's condition that suddenly warranted calling in a reference lab tech at 4:30 am? We would simply ask this question and tell the nurse we would have to consult with a Blood Bank physician before calling in a reference lab tech. We would also ask what physician is covering the patient in case the BB MD wanted clarification of the patient's clinical situation. This takes the issue out of the hands of both the nurse and the tech. Each has done their job and the decision is now in the hands of the physicians.

It is unfortunate it was not documented how the decision was made to wait until morning. Was it made by a blood bank tech based soley on the hgb result, or perhaps was a BB physician involved? Either way, the floor should have been notified and this documented.

[bbbirder]

As they say in Minnesota, Ooof-Dah...

This does sound like "An opportunity for improvement".

The Lab/BB should do a better job of documenting and communicating both within the department and to nursing (is that not a JCAHO patient safety requirement?). If you don't have a communication log, you need one. If you have one, do people use it?

Does writing up the nurse (unless she was rude/ profane) help the situation the next time? Or improve the relationship between nursing/lab?

Maybe your department needs a policy that says, "A reference tech will not be called in without Medical Director approval"? Polices can never cover every situation and good techs will deal with things as best they can. The minute you write a policy to cover one situation, another pops up.

Good luck.

Linda Frederick

[Eagle Eye]

As my boss always says--if it's not documented it was not done. It is very important to document all the communication with ref. lab and nursing unit (atleast in blood bank).

Hgb was 8.4 but, patient may have heart condition, may be bleeding...etc.

I do not see anything wrong when nurse inquire about the blood and tech called ref. lab. (RN was trying to do her job and was thinking about patient....why would you write up a RN who is trying to follow up on the transfusion order).

At my place some time we call ref. lab several time to check on the progress of the specimen sent.

In this case BB was responsible for not documenting communication with ref. lab and the floor. To me you can never say take a hike????( I do not understand this policy) come on may be RN wanted to give blood because of patient's clinical condition.

This kind of cases we take it to BB supervisior and let supervisior handle the situation. Usually supervisor would call the patient's physician or resident on call and explain the situation(many times we would bring BB director when situation can not be handle by supervisior) . Any time we have difficulty getting blood for a patient, we always notify BB director and keep him in the loop. Usually RN and Med tech are out of the picture at that point. But all the communication between supervisor and resident/clinician is documented.

Documentation....documentation ....is very important in blood bank.

[Jane]

Our policy is that anytime a reference tech has to be called in (night or weekend) we get the approval of our pathologist. This keeps us from having to "eat" all these excess charges when patients do not really warrant this and also keeps the pathologist in the loop.