Second Tube to confirm ABO/Rh on New Patients

[DFields]

Poll:

Do you require a second tube (drawn at a different time) to confirm the ABO/Rh of any new patient prior to transfusion (with other than group O red cells)?

Yes

No

[DHarts]

Today I went to the radiologist office for three different procedures. Each tech asked me the same two questions. What is your last name? What is your birthdate? Oddly enough, there was not a sole looking over their shoulder to verify that they asked these questions. Needless to say, I was impressed.

I would like to hear some strategies used in successful campaigns to educate nursing, medical, and phlebotomy staff on the importance of positive patient identification. It is working in some places. Anyone?

[GilTphoto]

Repeating the ABO on new patient's is a lot of extra work and extra cost. I chose to use a Phlebotomist Witness Statement, where the phlebotomist gets a nurse to witness the phlebotomy and both check the ID of the patient and the labeling of the specimen. The form much be signed by 2 individuals. Two signatures is a lot easier, faster and cheaper than two ABO's. We had our CAP/AABB inspection in October and the inspector liked the procedure.

I'm writing this from home, but if you'd like a copy of the form, I can send it tomorrow.

Gil

[John C. Staley]

Another question that should be asked to compliment this poll is how many answering NO are doing a second type on the original sample.

[bbbirder]

Gil,

I like this idea and would like to see your form.

How much trouble does your staff have trying to find someone to witness? Do you have any indication that some departments are 'fudging' this: just getting a signature, without the second person actually witnessing?

How did you introduce this to the staff and get buy-in?

Thanks,

Linda F

[Mabel Adams]

How do you be sure that each person doesn't assume that the other person "really" checked so they are just signing off to meet the rules. This may be almost subconcious and easy to mentally justify if staff is busy. I guess it comes back to buy-in by the staff--but how do you make sure the staff three years from now are equally convinced of the value.

[Mabel Adams]

I voted no, but we are still trying to figure out what we plan to do about this issue.

[janus]

Dear all

As I am not familiar with the "normal" number and kind of test you use before transfusion of red cells, I would like to know

-do all of you add a cross match (also after a second blood grouping)

-do you use blood from a new sample for the cross match

-do some of you confirm ABO/ Rh on another sample and use it together with an antibody screentest as a computer controlled cross match?

Data on labotory failures, which shows that they are an important cause of transfusion of red cell units with a wrong blood group, can be found on www.shotuk.org/home.html report 2006 page 49 Near Miss

Hei Janus

[GilTphoto]

Gil,

I like this idea and would like to see your form.

How much trouble does your staff have trying to find someone to witness? Do you have any indication that some departments are 'fudging' this: just getting a signature, without the second person actually witnessing?

How did you introduce this to the staff and get buy-in?

Thanks,

Linda F

The phlebotomists complained at first, but realized it's easier than getting another sample. The pathologist and myself brought up the plan to our Chief Nursing Officer, to get her OK. The policy was incorporated into the nursing manual and we gave an inservice to the nurses, so they would know we were going to request their help.

Yes, some are being fudged. The nurse signs the form without looking at the specimen. This is obvious when something is incorrect. The nurses and phlebotomists have been informed that this is serious business. If a patient is transfused the wrong blood because of misidentification, both people who signed that form will be fired. When mistakes are found, I go back to the nurse and explain the implications of not checking.

Most errors come from the nurse collected samples, but they are decreasing. Most errors are minor spelling errors on the typnex label, so far never that the wrong patient was drawn.

I'm not sure how to paste the form here. Can it be done? If not, send me your email in a private post, and I'll send it.

Gil

[csjuarez]

We began requiring a second specimen on patients without previous Blood Bank history in October last year. This was primarily in response to the CAP checklist question# TRM.30575. We're also trying to get an electronic identification system. If that happens the second specimen requirement will be dropped.

We've made a few exceptions to the requirement for a second specimen:

1) ABORh only orders

2) ABORh orders for the purpose of supplying components (FFP, CRYO, PLTS) - we do a second type on the same specimen.

3) Labor & Delivery patients (who rarely convert the Type & Screen to a Crossmatch), but if a Crossmatch is subsequently ordered, a second specimen is required.

4) Emergency transfusions - primarily trauma patients, but may also be other situations such as OR or L&D. We do a second type on the same specimen and get a second specimen as soon as it is feasible. We do a second type on the same specimen in these cases pending receipt of the second specimen. (Remember, if you're doing electronic crossmatches there has to be 2 types done prior to crossmatching, and we do electronic crossmatches.)

There has been and still is a good bit of complaining about it, but compliance is good - we insist upon it!

[Eoin]

I would hope the answer would be a universal YES. Eoin

[Melanie]

We are required to confirm type the original sample and this is done by a seperate technologist prior to transfusion.

[dstoever]

Poll:

Do you require a second tube (drawn at a different time) to confirm the ABO/Rh of any new patient prior to transfusion (with other than group O red cells)?

Yes

Yes if the same tech is doing the second type

No

No, if a different tech is doing the second type by a different method

[VACASE]

I hate to say this but we tried the same thing with 2 signatures and we still had some instances where the 2nd signer just signed apparently without really checking the ID of the patient drawn. We had a few instances where the tube was not labelled with the name of the patient actually drawn. This was the main reason for our having to add the process of drawing the 2nd tube. You expect non-laboratory personnel to take some things seriously (like patient ID) and unfortunately it's just another step that they resent having to do.

[Mabel Adams]

How much bang for your buck do you get from doing a second type by a different method? Rh is known to vary somewhat, but any ABO reagent that meets bureau of biologics standards should give pretty much the same results shouldn't it? Has anyone seen any differences?

I guess it would help because it would separate the testing in space and time. Gel would require a different cell suspension than tube, I assume, so your techs couldn't "cheat".

To have the biggest impact, we need to start with the biggest problems--blood administration, then specimen collection, then "in the BB." But how many of the latter are clerical vs. technical? Most that I have seen were clerical, although I did see one newbie mix the tubes up in his hand and read the reverse tube as the forward B tube and vice versa turning an O into a B.

If we are not going to test a separate draw then we need to make sure whatever we do will address clerical errors in the BB.

[Lisa W.]

We require a second sample drawn at a different time for patients with no historical data. We do allow 2 nurses or phlebs to "double check" in emergent cases. We are currently having problems with our admissions department not wanting a to stick the patients twice. We do not have electronic readers and our computer system (SoftBank) requires a second type on file from a second draw to allow electronic crossmatches. It is such a time saver to have the capability of electronic XM in an emergency OR situation. If we only have one draw we have to perform an IS XM, which takes longer and if the sample was drawn incorrectly, will not prevent errors.

[Lisa W.]

We require a second sample drawn at a different time for patients with no historical data. We do allow 2 nurses or phlebs to "double check" in emergent cases. We are currently having problems with our admissions department not wanting a to stick the patients twice. We do not have electronic readers and our computer system (SoftBank) requires a second type on file from a second draw to allow electronic crossmatches. It is such a time saver to have the capability of electronic XM in an emergency OR situation. If we only have one draw we have to perform an IS XM, which takes longer and if the sample was drawn incorrectly, will not prevent errors.

[cin]

We require a second tech to come in, make a new cell suspension, and perform forward typing (in addition to the forward and reverse that the first tech has done). We do not, however, require a new tube for this verification.

[David Saikin]

I cannot find that standard in the new CAP checklist TRM 035150. I think they have discarded it in favor of a question asking if 2 qualified individuals id the pat and unit at the bedside.

[SMW]

You may find the discussion points you're looking for in the Notes for TRM.30575 (Sept. 07 version).

[CPSHAN56]

We currently do not require a second blood type on a a new specimen collection if no previous history is available. We plan on changing that very soon. For those of you requireing a second specimen are you preforming both a forward and reverse typing?

[csjuarez]

For those who are AABB Accredited, it would seem to me that two complete (forward and reverse) ABO types would be required for computer crossmatching. Standard 5.15.2.2 requires "two determinations of the recipient's ABO gourp as specified in Standard 5.13.1" -- that standard standard specifies testing the red cells with anti-A and anti-B and testing the serum or plasma with A1 and B cells.

If you're not doing computer crossmatching, this probably wouldn't apply. However, testing the same sample has little value -- if it's drawn on the wrong patient or labelled incorrectly the patient could still get mismatched blood.