Issuing Products

[Seveets]

Hi,

I'm wondering if people could share their procedures/policies about issuing blood products.

We are a small 125 bed hospital with a very powerful nursing staff (if they don't want to do something - they don't do it) so having a hand off with them is out of the question.

We have a loose procedure of double checking the computer work, the unit and the transfusion tag with a co-worker (who may or may not be a blood banker).

Do people out there (in the lab) double check every thing including expiration dates?

I would like to streamline and eliminate some things so that we can concentrate on the most important ones.

How is it done where you are?

[jhaig]

We double-check everything at the time that results are entered into the computer. Included is the patient's full name, date of birth, medical record number, the unit's ABO/Rh and the patient's ABO/Rh, the donor number, expiration date, and the patient's R# (we use the Hollister wristband system). When issuing the unit, a blood bank tech is required to check all of the above info with the member of the nursing service personnel. The nurse is also required to bring physical proof - something with the patient's name on it, like a cardex stamp or the patient's blood bank report - so they can prove who the transfusion is for. No ID, no blood. Sometimes they try to say something like "Oh, I was just on the way back upstairs and thought you'd be able to give it to me". Sorry, sweetie, it doesn't work that way.

We also only allow nursing service personnel (RN, LPN, or nurse's aide) to pick up blood products. Unit clerks and students cannot receive blood products. We do make exceptions for students if they're accompanied by a nurse that will co-sign.

[Mary]

Our procedure is very similar to jhaig, but we also require that a nurse sign a "Request for Dispensing Blood and Blood Products" form. It has the patient's name and medical record number, product(s) requested, and number of units. We had a close call once when a nurse said verbally to a transport person that she wanted plateletpheresis and she really wanted plasma.

You are going to have to play the "tough guy". Try to use regulations as a reason. Will your patholigist back you up?

Good luck.

[John C. Staley]

Two questions before I attempt to give you an answer.

Do you utilize a computer system for documenting the issue of the blood products?

Do you have the capability of issue blood products via pneumatic tube system?

:juggle:

[Seveets]

Yes,

we use Medtech to issue the blood. It does the usual: date,time,checks ABO compatibility,looks to make sure a type and ABS are done, shows us patient's history, we tell it the units are ok, who is transporting it, etc.

We do not have a pneumatic tube system. For the most part, the one blood banker must leave the lab and deliver the blood him/herself.

Our problem is the double checking routine. We seem to be glazing over when doing it. I feel like our crossmatch tags have too much information on it but since it is being used as part of the medical record Standards tell us that that info must be there.

Specifically my question is what kind of check off list are people using to document that two people reviewed all information. Is it something in the computer, one sheet of checks per unit, a signout log, etc.?

[hmust1]

We are also a 120-ish bed community hospital and use Meditech. All blood is issued by a BLOOD BANK tech TO the requesting nursing personnel (RN, LPN, unit secretary). ONE unit at a time. (2 patients or 2 units = 2 trips by nursing or 2 people from their floor coming to BBK). The ONLY time a blood banker leaves the blood bank is to take blood to our OR refrigerator prior to a surgery (and as soon as I get the documentation together to demonstrate their non-compliance...we'll be rid of it). We DO NOT use our pneumatic tube system for blood products.

ALL other requests for blood mean that a TRAINED (and I use that term loosely) person from the nursing floor presents in the blood bank with a "blood release form." The form requires nursing to indicate:

1) "I have checked the pt name, MR#, DOB, and signed consent."

2) Complete patient info (usually in form of a registration label)

3) requested product

4) RN signature (we will NOT issue any product without a requesting RN signature...and the unit clerks only have to walk back to their floor ONCE before they take care of reminding the RN's about it. )

The form also has a place for the BBK tech to fill out:

1) unit#

2) date and time of issue

3) tech initials

Completed forms are maintained in blood bank.

This is done in conjunction with a blood product issue log (also maintained in the BBK) that nursing fills out at the time of issue and again requires pt name, location, date & time of issue, "messenger" initials, product type, and BBK tech initials.

All of the information on the sign out log is checked by the blood bank tech and entered into Meditech issue routine. Then TOGETHER we confirm the information that has printed on the Meditech Issue/Transfuse card with both the blood release form and the Meditech unit tag.

Sounds more complicated than it is...but like other's have said...use the regs to back you up. It also helps that we have a QI director and interm CEO with lab backgrounds.

Heather

[Lcsmrz]

The issue step in the transfusion process is probably the most critical to patient safety -- once it leaves the Blood Bank, who knows what will actually happen to it! Everything must be verified as correct -- name, MRN, blood types, unit number, product, exp date, compatibility -- and preferably with a second person. May things are FDA-reportable if something gets past this step. It should not be taken lightly by anyone in the facility ...

When requesting a change in nursing practice, I send a copy of the standard/regulation/etc and tell them this is why it's important. Occasionally, they come up with something even better!

[cmiller]

We are a 115 bed hospital and use Soft Computer system. We also use the Hollister banding system.

At time of unit issue, a RN must come to the Blood Bank with a completed Component Request Form. At bare minimum it must have the patient's name and Medical Record # on it (usually they use a registration sticker/label.) The form also has a place to check what product they need to transfuse as well as the date, physician, and diagnosis.

If the RN doesn't have the request form - no blood is issued.

A MT or MLT retrieves the unit and all of the information (Patient name, MR#, patient ABO/Rh, unit ABO/Rh, unit expiration date, and Hollister #) is compared to the Component Request Form, the Unit/Compatibility Tag, the Transfusion Slip, and the Computer system by BOTH the tech and the RN.

The unit is issued in the computer system at this time and we enter the RNs initials & employee number as the person picking up the unit.

The tech and the RN are required to inital the transfusion slip with date/time as to when the unit was issued.

Only in cases of trauma, etc in the ER or OR do the techs take blood from the Blood Bank, and even in those situations. The check by the tech and the RN are performed at the bedside.

Hope this helps!

Nursing needs to understand the importance of these checks and they should also be confirming all of this information again at the bedside before the transfusion

[Mabel Adams]

Joint Commission regs should back you up. Nursing usually pays attention to them. They have some pretty clear ones now about patient hand-offs.

Then you need to look at the process for where the greatest risks are: 1) the nurse IDs the patient for whom she needs blood. 2) a request that positively IDs the patient goes to BB by whatever means you use (usually at least name, an ID number & what product) 3) BB staff has a way to make sure they get the right product for the right patient out of the fridge 4) BB staff has a way to make sure paperwork is attached to correct unit and all info on it is correct, that the unit is indate and meets needs (irradiation etc.) 5) The unit goes to the right floor 6) nursing makes sure the unit being hung is the correct product for the patient being transfused. Generally at least two identifiers are required for every hand-off. There are myriad ways to do this, some more efficient than others. None will work if the people involved don't believe it is important and worth their time.

Sometimes plausible but frightening stories help people see the risks in the process. If you don't have any real near misses, write some scenarios based on your current policies that show how one small assumption in the process can be fatal to the patient. Then ask them if it is okay if that patient is someone in their family!

[Mabel Adams]

Joint Commission has some pretty clear regs now on hand-offs. Nursing usually listens to them.

[Mabel Adams]

Look at the critical ID steps in the process: nurse has to ID which patient she plans to transfuse with what; she needs to transmit to BB patient ID and product; BB needs to get the right product for the right patient out to send; BB needs to make sure the paperwork on the unit is right, plus check outdate, inspection and pt. needs (irradiation etc.); unit needs to go to right floor; nurse must positively ID both patient and unit before hanging. Make all these airtight and you will prevent many problems.

However, nothing works if those involved don't believe it is important.

[Seveets]

I have searched for any regs dealing with someone coming to the lab and doing a hand-off. I can only find regs/standards about double id ing the patient and two people actually hanging the blood. Can not find anything to help back me up about nursing staff coming to pick up their own blood.

[geekay]

Hi there,

It is better to have a system wherein " a double check system" is implemeted for all the data related to collection till issue. It can be done by a colleague who could be a junior or a senior technical person. In the ward also, the data need to be checked twice either by a seniot nursing staff or a doctor. Likewise, the data enetered into the system from the registartion time, need to be supervised on a daily basis by a senior person,preferably technically competent.

[cin]

I can't imagine nursing staff blatantly jeapordizing patient safety...but then again I'm not too surpised. Currently, we check off (patient name, medical record number, blood bank armand number, unit type, patient type, unit number, and expiration date) with nursing staff upon issue. Prior to issue, we have a second tech check off the same and initial. After issue, nursing does the same on the floor prior to transfusion. So, in effect, we have a triple check to ensure all info is correct and the receiving patient is correct.

[cin]

I can't imagine nursing staff blatantly jeapordizing patient safety...but then again I'm not too surpised. Currently, we check off (patient name, medical record number, blood bank armand number, unit type, patient type, unit number, and expiration date) with nursing staff upon issue. Prior to issue, we have a second tech check off the same and initial. After issue, nursing does the same on the floor prior to transfusion. So, in effect, we have a triple check to ensure all info is correct and the receiving patient is correct.

[bpkelly]

I am clinical specialist for a large system. The written order must be presented to us to pick up blood products. Theorder must include the correct verb-i.e.- give, infuse, transfuse- if it doesn't- no product. The order must have 2 patient identifiers on it- in our case full name and medical record number. One of our facilities just went paperless but we still require them to print the transfuse order and bring it to Transfusion Service. We then review the orderand identifying information with the tag, blood product and with the information we pull up on the Cerner dispense screen. There are no exceptions. We have the full backing of our Medical Director and our lab directors and VP.

[Seveets]

UPDATE:

The powers that be and shall remain nameless have agreed to try the whole alien idea of having an actual RN leave and come to the lab to pick up blood. I think I have a usable double check form for all the important information BUT what kind of form should the nurse bring down with her? I would imagine it should include the patient's name, medical record number, and perhaps the patient's blood bracelet number and what type of product they want. Does anyone using MEDITECH have this form and how to get it??

[Lcsmrz]

We use Meditech, and we ask them to bring a screen-print of the EMR order to transfuse. It positively identifies the patient, plus gives us a copy of the infuse order to verify.

[quint]

Joint Commission has some pretty clear regs now on hand-offs. Nursing usually listens to them.

This is you best course.

That way they are the bad cop.

[shelleyk482]

I have attached a copy of the form that we implemented a couple of years ago. In Nov, nursing administration began requiring that a copy of the physician's order also be brought down. We continue to use both forms since there is a nursing checklist of items on the top of the form (for some reason you can't see this part unless you do a "print preview" or a hardcopy). This form "B-25" (as we call it) is a 2 part form; the top copy goes on the patient's chart and the blood bank retains the bottom copy. We have virtually eliminated wastage due to blood being issued w/o a consent on the chart or the patient not having a patent IV access. Our nursing administration is very supportive (the form was developed using an interdepartmental team) with this process but it took the blood bank filing "Risk Management" reports for all wasted blood products and copying nursing and operations VP's on each report. Once Nursing Administration got tired of having to respond to all of the reports, they decided that the process needed to be "cleaned up" and that it would take both the BB and nursing to be involved to make it succeed. Our facility now requires that any & all transfusion related errors, omissions, deviations, etc. result in automatic disiplinary action and we have actually had 1 nursing director fired for repeated problems in her area (no single nurse was involved in more than 1 incident).

B-25 rev 08-31-07.doc

[Mary]

Do you still used washed blood?

[shelleyk482]

Yes, we do. We have an "in vivo" crossmatch procedure (which has been in place here for years and no one knows where it came from) that is used for WAA patients when we can't furnish crossmatch compatible cells and it requires washed blood; we have a large Heme/Onc program so we see a couple of these patients a week. We also support an active children's hospital and may need to use washed blood if we cannot get RBC's < 7 days old for open-heart surgeries & neurological surgeries (whether or not we wash is the surgeons call- depending on the patient's clinical considerations).

[kph]

We require that a Blood Bank Requisition Form, labeled with a patient ID label (or at least the patient's full name, med rec# and DOB) be brought to the Blood Bank by a badged hospital employee to issue blood products. The products are double checked at the time of issue by the hospital staff reading patient and product identifying information, from the Transfusion Record label attached to the product, to the BB staffer who checks the info in the computer and on the requisition form. Both sign the label attached to the product, then place the product in a biohazard bag or on ice for transport.

JCAHO, AABB and CAP are fairly detailed in how product issue should be conducted.

Hope this helps.

[Mabel Adams]

Why would washing cells help with a warm auto? Just removing other possible sources of reactions???

[AMcCord]

I had a hemotologist request washed red cells for one of his patients with Cold Agglutinin Syndrome secondary to leukemia. He stated that he didn't want 'extra proteins hanging around' for his patient to react with, but didn't go into any details. Neither he nor his partners have requested washed cells for WAIHA.

I did some reading (Immune Hemolytic Anemias - Petz, Garratty) and am speculating that my doc was using the rationale that washing the cells would remove complement, thus reducing hemolysis. Petz and Garratty talk about work done based on the treatment of one patient with CAS who was noted to have 'low complement'. The reference goes on to say that they would not recommend the use of washed RBCs based on this rationale without more information/documentation. Maybe this is the reasoning being used to transfuse washed cells to patients with positive autos/incompatible crossmatches...?