Retyping

[krichards]

I have been looking into instituting a second sample requirement for retyping our patients with no history. I have some questions, though, and would like to see what other facilities are doing.

Our phlebotomists are using handhelds for all their draws. In my mind, because the patient has been positively identified prior to the label printing, these do not need a second draw. Is that correct?

Outside of the ED, the nurses will not have handhelds available for their draws. Is it too complicated for everyone if I institute a requirement for second draws for only non-handheld collected specimens? Since the handheld labels look different, the techs will not have any trouble distinguishing. Has anyone else tried this? Has anyone had much luck getting other departments to use handhelds? Our ED currently refuses to use them, claiming that they are too slow. I'm almost sure I can cure them of that, though.

How are others handling their pre-op patients? These seem to be the majority of the patients we see without previous histories. Our surgical staff is already overloaded, and I'm afraid if I put the burden on them to collect a retype at the time of admission, that they may run out of the hospital screaming.

I appreciate any input.

Karen

[jhaig]

Our policy is as follows:

Any patient that is to be transfused with blood products needs to have their blood type verified by two separate draws at separate times, preferably by separate phlebotomists. If the patient has a verified blood type history in the computer, that counts as the first type.

If there is no history, then the patient needs a separate draw. Many times the hematology department has a tube we can use from a previous draw, so our actual number of re-sticks is minimal. If there is no time to get a redraw, the patient is given group O products until we get a second draw.

As far as your O.R., a fingerstick would work just as well. Explain to them that it is a patient safety issue recommended by the lab's regulatory agencies and be sure you have your pathologist on board with your new policy. I'm sure they'll see it your way:cool:

I wouldn't have a different procedure for hand-helds vs. non-hand-helds just so you can keep everything the same for every draw. The idea is to have two specimens from two separate draws so you can verify the patient's blood type twice before transfusion. Just because your hand-held read the barcode on the patient's wristband doesn't mean that the band is on the right patient. Another set of eyes doing a second draw will take care of that.

[John C. Staley]

Why are you looking into instituting a second sample requirement? Did you have a serious problem and this is your corrective action? Is your current process flawed and this is your best solution?

I'm just curious what the driver here is.

:raincloud

[Mini Me]

I work with two different institution and they both require the recheck as JHAIG has stated. Two different draws at two different time on the same patient preferably drawn by two different phlebotomists.

It seems like some new regulation that was imposed by regulatory agencies I guess.

[Dr. Pepper]

John, if you never have seen a mislabeled lab spec in any dept God bless you and your institution! Hand-held devices reduce the risk of misidentification but do not eliminate it. We have had the 2-typing rule in place for several years and it's worked out well. We use any lab spec from a different draw to verify a "first-time typing' only, not for any pretransfusion testing. OR cases have the highest 1st time rate, about 50%. We don't bother retyping type and screen cases as they're not likely to take blood anyway. We do retype the cases where we've actually crossmatched their real non-O blood type. There's a dedicated phleb in the OR. The day before surgery we send up a list of patients needing redraw for a second typing or repeat type and screen because they've been pregnant/transfused recently and their PAT spec was too old. They get drawn as they get to the pre-op holding area. No one seems to mind.

[Philip Thornton]

You can use multiple options to reduce the risk of mistransfusion in non-emergent red cell transfusions in addition to or in lieu of drawing a second sample on patients with no history. According to CAP "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 use of a second manual banding system, while currently acceptable, is probably not as effective as the above two options. Other approaches capable of reducing the risk of mistransfusion may be used." It sounds like you've implemented the electronic identification verification system within the lab. If you could get ER and the rest to implement you would be well on the way to mistransfusion risk reduction. Other options may also be considered. We are implementing the electronic identification verification system. If you've had major issues with identity verification in the past, you may wish to implement multiple options.

[krichards]

John,

The main reason for implementing the second draw is a recent series of major errors. Of course, all patients involved were drawn by the same ED employee....one of those people who have access to, but refuse to use the handhelds.

Currently, our handhelds are only accounting for around 60% of our patients. The rest are coming from ED, outlying outpatient areas, pre-ops, nurse collects, etc.

[John C. Staley]

Seems like a lot of extra work simply because one ER employee won't comply. One employee having problems does not indicate a process problem. Why change a good and simple process because no one will hold one employee accountable.

One more reason for heading out to pasture.

[Max001]

We did both of the above. Patients who were scheduled for surgery would wear their banding system home and not remove it. Otherwise a new sample would have to be drawn on the day of surgery for anyone who might require blood.

Frequently the patient or even the OR staff would cut off the bracelet when preparing for the OR. (ironic, no?)

We've had distraught surgeons and anesthesiologists run up to the blood bank with the cut off band in their hand, demanding that we use this sample for the XM. (rolls eyes).

They just don't get it. Transfusing a blood product is hazardous and must be done 100% correctly all the time, no matter what, unless you have battlefield conditions and everyone gets O packed cells and AB plasma.

[Max001]

Seems like a lot of extra work simply because one ER employee won't comply.

I agree, but as far as I'm aware every major hospital BB follows that two sample rule on patients without a transfusion history.

I'm surprised that people are still debating this. Did I miss something. This was SOP even in the 1990s and before.

Don't know when that advisement was put out but as far back as I can remember we required a separate T&H and no one ever complained.

[John C. Staley]

Never done it in my career and I know a number of facilities that don't do it and they range from 20 beds to 500+.

I stand by my philosophy that complicating processes do not make them better. Keep it simple, keep it understandable and keep reminding everyone why they must follow the protocol and make them accountable when they don't!

[jhaig]

Never done it in my career and I know a number of facilities that don't do it and they range from 20 beds to 500+.

I stand by my philosophy that complicating processes do not make them better. Keep it simple, keep it understandable and keep reminding everyone why they must follow the protocol and make them accountable when they don't!

I wish it were that easy. It would be fantastic for every phlebotomist / tech to draw the right patient the first time, every time. Anyone that needs multiple reminders that a misdraw could lead to a patient's death should find another line of work anyway.

But I don't see a redraw as a further complication. I see it as a necessity to ensure that the right patient has been drawn. Why not take an extra step to prevent possible complications and enhance patient safety? Our hospital's risk management and medical exec. committees fully endorsed our redraw policy and it has worked out great, not to mention that CAP may require it in the future.

Everyone should be accountable for their actions and for following protocols as they are written. But by the time someone is held accountable, the damage could already be done.

Save some room in that pasture. If I can find a way to retire at 39, I'm there:cool:

[Mary**]

Do you draw a second specimen on orderes for a new patient for plasma products only?