NEW PATIENT: CONFIRMING ABO/Rh

[JerryB]

Our hospitals' current policy, if there is no previous patient history, is to request a second sample be drawn and submitted for confirmation of ABO/Rh. We are a nationwide group of hospitals with access to each others database. My suspervisor is currently contemplating the following: instead of requesting a second sample for confirmation, we are to check the nationwide database and if the patient has an ABO/Rh history, we are to use that history as our confirmation. Our system is based on social security numbers as a patient identifier. I'd like to hear any opinions about implementing this new policy. I've checked the CAP checklist questions and I'm a bit baffeled about this policy.

[Lcsmrz]

There is no consensus on handling this question yet. While commendable that reducing ID errors in the Blood Bank is getting high profile, I'm not yet convinced that performing a second Veni on a patient without a historical record is the correct answer. I vaguely remember that the chances of getting the same blood type on a random sample is over 50% -- there is no substitute for properly performed ID at the bedside!

If I were a patient, and a phleb wanted to restick me after just being drawn an hour ago for the sole purpose of confirming that the first phleb didn't make a mistake, not only would I refuse, but I would make sure everyone in the facility knew of my name and what bed I was in. Pray that I don't become a patient in your facility ...

If your patient database is keyed by SSN and contains the patient blood type (antibodies even better!), I can't see a reason for not using it as a second check; if a discrepancy exists, a redraw would be required. But I question whether a patient's SSN would hit a record in such a database, unless the facilities using it were in close geographical proximity or if the patient was part of a national health system , such as the VA or Canada.

[JerryB]

Lcsmrz,

I think I need to clarify several things.

1. We have come across several occassions where the second Veni did

not match the first;second or first phlebotomist's drew the wrong

patient. As the second draw on new patient's (no blood bank historical

info) is hospital policy, we haven't had any complaints from staff nor

have staff from patient's.

In fact, many are appreciative of the extra check as most patient's

are apprehensive of receiving blood and/or blood pdts in the first place.

2. We ARE part of a national health system.

Your argument was quite thought provoking. Any response to the clarifications?

[VACASE]

JerryB,

It sounds like we are part of that same system of hospitals and if we do find an ABO/Rh through Remote Patient Data we use that as the confirmation. If they don't match, however, that is a whole different story.

If there is no remote patient data we still do the 2nd draw. I, as a patient, would not mind a 2nd stick to be sure they got my info right. Human error happens everywhere. Our 2nd draw is in a smaller tube where only a small amount of blood is drawn. We only do a front ABO/Rh type as the confirmation.

[tbostock]

We try to use a separately drawn sample as a recheck (a CBC tube, for example) so we don't have to restick patients. We rarely have to stick them again just for the recheck.

[Packer Banker]

Not only is there tech error, phlebotomy error, but insurance fraud as well to consider. (where a patient comes in with the insurance card of another person) I don't know that I could necessarily trust a hospital across the country and their identification procedures. This is a second type of course, but we all know that mistakes have been made...

(Just another thought to throw out there!)

[Lcsmrz]

A second blood type on a second collection event at a different lab with different techs and reagents lends more confidence than a second blood type from a second collection or from a different tube from the same collection. Still, there is no substitute for a proper collection with a proper patient ID, and if an issue exists, I hope people were terminated -- zero tolerance in the Blood Bank!

The best system I ever heard was a fingerstick blood group after the hospital band is attached, and it is written on the band. If the band is removed or the blood group becomes illegible, the fingerstick blood group is repeated after affixing the new band. It is verified at the time of transfusion as part of the bedside checks. It would be difficult to get around this system without alot of effort and creativity.

If I had access to a national database keyed on SSN, I would use it, not only for the blood type, but (more importantly) for antibodies, special requirements (irrad, WRBC, etc), and other important comments. A second draw and patient interview is required if the results don't match.

Although better than anything else, electronic verification is not foolproof -- as we all found out when nurses started doing POCT.

[Dr. Pepper]

We do it like Terri from Poughkeepsie, using another lab spec from a different draw, and rarely have to redraw patients, particularly inpatients. We have not had a significant increase in use of group O RBC for the "one time only" typing patients. And it seems all the same to me if you have two typings to look at from two recent draws, or you use your own past records, or those from a regional database, or from a previous LIS whose database has been converted into your current system, so long as your identifiers (name, DOB and unique ID# such as med rec# or SS#) match.

We have also seen blood types change due to insurance fraud (once in a blue moon with our prenatal patients), but this will create a discrepancy that you evaluate. In any case, for ABO catastrophe to strike, you would have to have two back to back quite unlikely events (wrong patient drawn, lab mixup or mistyping, deliberate fraud). As has been pointed out, there is no substitute for just doing it right from the beginning: maintaining the chain of ID from collection to testing to transfusion.

[reidhospbb]

A point to remember, SSN's get reused once a person expires. Therefore, a birthdate AND the SSN would be a much better solution. We don't use the SSN for anything except as another piece of data on a person.

[ckcheng]

I personally do not like redo the same sample when historical ABO is not available cuz if blood is collected from the wrong patient, redo will never get the right blood type of the recipient.

Second stick can be done by nurse during IV line insertion - save a stick.

One-stick-two-samples should be discourged cuz blood from wrong patient still remains the wrong patient.

CK Cheng, MSc, SBB(ASCP), CQA(ASQ)

Jan 15, 2009

[TRose1]

Our hospitals' current policy, if there is no previous patient history, is to request a second sample be drawn and submitted for confirmation of ABO/Rh only if the patient is not group O and is a candidate to receive red cells in the next 72 hr. period. This cuts the redraws to a minimum and also prevents any ABO related transfusion reactions.

[NedB]

A cheap alternative to two samples is to have the Patient identified by two people and for both of them to sign the tube. Even in the OR this is possible.

What is this national database keyed to the SSN? Is this military, government or private? And most important, does it include antibodies? and antigen testing?

[JerryB]

A cheap alternative to two samples is to have the Patient identified by two people and for both of them to sign the tube. Even in the OR this is possible.

What is this national database keyed to the SSN? Is this military, government or private? And most important, does it include antibodies? and antigen testing?

NedB, this is indeed government. Thus far historical records of antibody and antigen testing have not been mentioned...but..who knows.

[Nancy L.]

We are one of the those who take the "cheap alternative". We have 2 people identify the patient and each one signs the tubes. There is also a place to enter this information into the computer so we have permanent documentation of the identity confirmation.

[Debbie McCaskill]

Approximately a year ago we were cited by CAP for not reconfirming ABO/Rh on patients. We began asking for second tubes for retypes on patients with no historical data. So far, we have yet to pick up any misdraws and we have not had complaints from the patients. I guess if we pick up one error it may all be worth it though!

[bxcall1]

If a patient has no history with us we retype them using the same sample, different tech. This doesn't address the 'wrong patient drawn' issue, but we believe that the Blood Bank armband number does this. We assign each patient a unique BB armband number that is on each crossmatched unit, the patient, the specimens and all BB paperwork. The number must be checked everywhere by nursing prior to transfusion.

Edited January 26, 2009 by bxcall1
poor typing

[NedB]

Thanks Nancy L. Cerner does not allow two identities for phlebotomy, but htere is always the comments section. I thought I might have to make a form that I would have to permanently file. Tying it to the phlebotomy in the computer is far better.

I don't believe the AABB will be satisfied with two techs testing the same sample - that does not eliminate the misidentification of the Patient issue, unique arm band number or not.

[Debbie McCaskill]

bxcall1, we did the same as you before being cited by CAP. We also used and still use the typenex armband. That STILL did not satisfy our inspectors! That is why we ended up asking for the second specimen. We will use a sample from another department if it was not collected at the same time as the crossmatch specimen to avoid another phlebotomy.

[bxcall1]

Can you help me out on which AABB Standard would address this? The closest I found so far is 5.15.2.2 which addresses computer crossmatching. In this standard retesting the same sample is an acceptable method of recipient ABO group verification.

[Dr. Pepper]

Bxcall1, AABB standards limits the 2 typing rule to computer XMs as an extra layer of safety since you woudn't have an incompatible wet I.S. crossmatch to fall back on. The typing result is, in effect, your crossmatch. On p. 451 of the new tech manual they do discuss the standard of comparison with past records and point out that one typing would not detect "wrong blood in tube" (WBIT) and suggest that the second typing may be helpful in detecting WBITs. But that's as far as AABB goes. The CAP is firmer on this issue mandating a plan to reduce the risk of mistransfusion and listing the second typing as their first option. I sleep better at night since we've gone that route.