Who draws BB samples at your hospital?

[bmarotto]

We recently identified a WBIT drawn by a phlebotomist. Administration thinks the solution is to have BB samples drawn by BB techs. Our COO is a former Blood Bank director who 30 years ago came from a hospital where BB techs drew or "witnessed" the drawing of all BB samples. This is not a viable option for us. The techs are stretched too thin as it is. Second shift is busy and only has two BB techs. Weekends and holidays there is one tech per shift. I see this as a knee jerk reaction that will cause more problems in the end. Anyhow, I was asked to find out if other places of our size restrict the drawing of BB samples to BB techs. We are 360 beds and transfuse about 15,000 units of red cells a year.

As an aside, we planned to have bedside scanning by now but it turns out our administration purchased a 3rd party patient ID application for medication admin, sample collection, and blood administration that can not interface to our lab or blood bank systems. The lab was never consulted prior to the purchase. With this project seemingly at a dead end, I want to implement a policy of requiring a blood type on a 2nd sample prior to transfusion. That being done, I see no point in requiring BB techs to draw the samples.

[Mary**]

:bonk:I have been through exactly what you are going through, only in reverse. I am the supervisor of a Blood Bank that historically only accepted BB specimens that were drawn or witnessed by a Blood Banker. This was established by my predecessor. I was told it was in reaction to WBIT many years ago. I was also in charge of the phlebotmists for a LONG 10 years and was very aware of the problems that occur in that group, so I continued with that policy. As our staffing kept decreasing continiously, my lab manager decided that the phlebotomists should be trained to draw BB specimens. I was very fearful at first. I decided that the phlebotomists with a proven track record of no patient misidentifications and some experience would be trained. I must admit that it has worked out very well for more than 5 years. At our current staffing levels, there is no way the BB techs could draw or witness all specimen procurements now., nor do most of them have the skill set to draw sucessfully. I personally train them most of the time , emphasizing the importance of the patient identification. I also monitor "smaller issues" like no date and time, etc. as part of the QA program and report my findings to their supervisor and to them.

Even a Blood Banker could make a mistake, but it is probably less likely.

Good luck.

[krichards]

We allow phlebotomists, and anyone else who has documented training, to collect BB specimens. We are 350+ beds, with about 10,000 units transfused annually.

We would never consider allowing, much less requiring, our BB techs to do their own draws. We rarely have more than one tech working, and if they are out drawing, who is going to get the blood ready for the next trauma or bleeder that walks through the door? Can the nurses or phlebs work up antibodies???

You do have two good options: You could have all the patients delivered to the BB so that your techs could draw them. Or, you could ask the COO, with his BB experience, to do these draws for you.

We did implement bedside scanning this year. However, our nursing units, most notably ER, refuse to use them. Their list of excuses goes on forever. I'll never understand why so few nursing personnel understand the importance of patient safety. As always, our safety measures are only successful if they are used by everyone all the time.

[Karen Olsen]

We are about the same size facility as you. Our Phlebotomy team and staff from select areas of the hospital(ER,Surg, Dial,NICU) are trained by the BB supervisor to draw BB specimens. We have an additional staff member identify the patient at the time of the draw and sign as such. We also HAND label our BB specimens from the patient armband. I know - I know!! But we do not have mislabeled tubes! We are holding our breath for the electronic PID system! Everyone is very tired of hand labeling tubes. Our Inspectors love us though!

[tbostock]

We have about 250 beds, and we allow phlebs, techs, and nurses collect BB specimens. We have a very limited busy Blood Bank staff and could also not "spare" them to leave the Lab for specimen collection. We also handlabel tubes from the wristband, a very ancient concept that results in clerical errors. We also do blood type verification by collecting two separate specimens from patients, one of them preferably drawn by lab staff.

[Likewine99]

We are a 350+ bed Level II trauma center, nsg draws everything except what our phelbs collect in the OP lab.

The organization has instituted a "three strikes and your're out" policy, tied to our code of conduct for neglect of duty. If a sample is mislabled for anything they "supposedly" are counseled.

We enforce this with our OP lab phlebs but I'm not convinced it's happening on the nsg side.

[John C. Staley]

Wow Bev. The nonsense never seems to end. Was this a one time occurrence and have the details been identified? If so then counseling and retraining the individual, if possible, should be all that's needed.

If they start dumping more on your staff I assure you the mistakes will increase. My previous facility was 350 beds and phlebotomists, nurses and, heaven forbid, even physicians would draw samples for us.

[Eagle Eye]

we are >500 bed hospital. Anyone who is trained and competant can draw our specimen. We have separate arm band for the patient requiring blood transfusion and our specimen labels are hand written. We have lots of rejection from ER.

[bmarotto]

Hi John,

Yes, this is a rare event, especially for a lab phlebotomist. Unfortunately, this was not a patient we had a previous type on. We do get WBIT from nursing collects maybe twice a year but generally nurse collects are in the critical care units where patients have already had a type & screen so we detect it in the blood bank. Guess what? We write an incident report and nothing happens. We idenitifed the root cause of this incident. Labels for the phleb rounds print on continous feed label stock. There is no blank label between patients. A phleb comes in at 5:30 am for the morning draw, separates the labels by patients and sorts by floor. There are about 150 patient draws in the am. The patient in question only had a TS label. We believe that label was left with the strip of labels for the previous patient, who had a long list of test to be drawn. The phleb checked the labels against the ID band but apparently did not notice the very bottom label was for a different patient. She is a very competent phleb and is sick over this error. Lab LIS is working on having a blank label between each patient. All phlebs are being retrained and told all BB tubes MUST be checked against the ID band after the blood is drawn and the tube labeled, even though the ID band was checked prior to phlebotomy. Nursing thinks their two signature policy (which I objected to from the start) is foolproof. One nurse even said "we are licensed staff and take this seriously". I know otherwise. I have received samples from the ED signed by two nurses with absolutely no patient ID. I expect our Medical Practice Committee to approve the 2 independent sample policy today and it better apply to all blood bank samples; not just phlebotomy collects. It is the ED I am most concerend about. Many of those patients are new to us. Once the nurses learn of the 2 sample policy, I am afraid they will collect two samples, send one, and then when we say we need a second...well you see what I am thinking.

Incidentally, we had an incident 9 years ago due to a WBIT drawn by a nurse. That is where the two signature policy came from. At that time, nursing suggested that maybe phlebotomists should draw all the samples because that is what they are trained to do and nurses are so busy doing more important things that they may not pay as much attention when drawing blood. Funny how times change, isn't it?

[tbostock]

"Once the nurses learn of the 2 sample policy, I am afraid they will collect two samples, send one, and then when we say we need a second...well you see what I am thinking"

If you are going to have two samples, don't allow the same nursing unit to draw both samples. The same nurse will make the same mistake if she thinks the patient she is drawing the sample from is the correct patient. Here's the way that we do it.

[tbostock]

Oops, I hit enter too soon...here's how we do it:

If the patient is type O, no BTV (blood type verification) needed

If the have a previous history, no BTV needed, because we have it on file

If they are non-type O with no history, we try to use a separately drawn CBC (drawn by our staff) for the BTV. If they need blood before that, we send up a phleb to obtain the second sample.

Thankfully, we do not have to restick patients very frequently.

[John C. Staley]

Bev, sounds to me like the blank label between patients idea came after a well done root cause analysis. It also sounds like a simple yet effective solution to the identified cause of the problem. You know my feelings that simple is always best.

Good luck and give the phlebotomist my best. They are probably beating themselves up worse than anyone else could over something like this. Especially if they are one of the good ones.

[AMcCord]

Almost all of our specimens are drawn by phlebs with a tech (not a blood banker generally) helping out when they are overloaded. We accept specimens drawn from lines by nursing or ER physicians only when someone from lab witnesses the collection and IDs the patient at the time the specimen is collected. If we arrive to find a syringe laying on the patient bed or a nearby counter...redraw. I make sure that I have a serious 'chat' with all new phlebs about labeling Blood Bank specimens and go over the policy with them. They also know that they will be held accountable and required to fill out a variance for any errors found in their specimens. We are not large but there is no way Blood Bank or even a tech could draw every Blood Bank specimen.

[jhaig]

All of our blood bank specimens are collected by lab staff for now, but we're in the process of training nursing staff to handle all of our draws. Blood Bank staff can barely find time to do menial tasks such as, oh I don't know, surveys, QC, inspection preparations (you know, stuff that's not that important) as it is. To have the Blood Bank draw all of their work would be a disaster. I personally train all new phlebotomy and technical staff about draws for transfusion and I purposely scare the you-know-what out of them with stories I find on line about mistransfusions, hemolytic reactions, and lawsuits.

We also use a separate wristband and unique transfusion number and will continue to do so until barcoding becomes a more financially realistic option. No number on the tube means no blood and reject the specimen, without exception.

[debbylb]

We also have a requirement that a second person must identify and witness the BB draw. Both sets of initials must be on the tube. The witness must be an RN or a physician. Any deviation from the name that is on the wristband is rejected including middle initial, prefix or suffix. Medical record number, date and time. It must all be hand labeled, Our BB will not except any tube for transfusion that is not hand labeled.