Blood Bankers Help me...

[ahalim]

Sure! in case of anemia and thrombocytopenia. PRBCs have no functioning platelets. and in case you give Fresh Whole Blood you might expose the patient to circulatory overload and practically speaking is not easy to deliver in a reasonable time. also, you can give SDP which has a bigger amount of plat. in only 50 ml. this is my idea!

[jcdayaz]

We have worked long and hard to build relationships with the Nurse Educators. These Educators do just that - train nurses and perform annual competency training. Transfusion Med: importance of patient ID, reaction recognition and proper handling of components are included in all RN training and competency. We've had few issues since instituting this.

We also have a (mostly) non-punative hospital-wide Incident/Medication error reporting system. The goal is better patient care, not discipline. We are not incident-free, but are doing much more root cause analysis and looking at and fixing our systems.

It takes a while, but it does work.

Hmm..non-punative Incident/Medication error reporting system??! If there is no "punishmnet", so to speak, what is the nurse's motivation for actually doing it right?

I am very hesitant to make this next statement...IT HORRIFIES ME!!! Our hospital recently added a state-of-the-art Neuroscience wing and L&D wing. The neuroscience wing consists of a Neuro Med-Surg floor and a Neuro-ICU floor. It is these two floors that the nurses (or POCT's) consistently draw the wrong patients...or draw the right patients and apply the wrong label...It doesn't seem to matter how much education is provided to them....still the same irresponsibility and as far as I am concerned, medical malpractice!!

Any suggestions?

[Malcolm Needs ☆]

That's why I'm more in favour of fair and proportional blame.

[RR1]

The National Patient Safety Agency (NPSA) in the UK states that hospitals with an 'open' incident reporting culture are the ones that improve. Everyone must be encouraged to report these events without fear of blame and punishment attached. As Kate mentioned a causal analysis must be performed to see where the problems really lie.

In the case jcdayaz has stated, with nurses constantly drawing the wrong patients, thisshould be properly investigated to see why, even after training this still happens. It could be due to staff workload or even the basic arrangement of the room and trolley etc where the phlebotomy is performed.

[lburk]

We often give pheresis platelets that contain ABO incompatible plasma to the patient's blood type due to non-availability of ABO compatible platelet inventory. I would not recommend giving a platelet pheresis that contains ABO incompatible plasma to a red cell unit thru the same IV site at the same time, i.e., group "O" pheresis and group A red cells. Anyone else have any comments on that?

[L106]

Hmm..non-punative Incident/Medication error reporting system??! If there is no "punishmnet", so to speak, what is the nurse's motivation for actually doing it right?

I am very hesitant to make this next statement...IT HORRIFIES ME!!! Our hospital recently added a state-of-the-art Neuroscience wing and L&D wing. The neuroscience wing consists of a Neuro Med-Surg floor and a Neuro-ICU floor. It is these two floors that the nurses (or POCT's) consistently draw the wrong patients...or draw the right patients and apply the wrong label...It doesn't seem to matter how much education is provided to them....still the same irresponsibility and as far as I am concerned, medical malpractice!!

Any suggestions?

I share you view. (Isn't it amazing the we can do all the fancy stuff....Neuroscience ICU, Open Heart Surgeries, etc., but yet not follow rather simple, basic procedures?? It drives me nuts!)

Regarding suggestions: Does your facility have a Risk Management Department, Regulatory Compliance Officer, or something equivalent to Director of Quality Assurance? You might try to work with one of those individuals if you aren't making any progress with the Nursing Directors of the problematic units.

[Avid123]

We issue platelets to OR in a room temperature cooler that is smaller than the coolers we use for RBCs. It has a sign saying it is a RT cooler with no ice. As for RBCs, we try not to issue multiple units in a cooler to the med/surg floor unless the patient is being dialyzed. OR, ER and ICUs can get multiple components in a cooler. We have a limited amount of coolers and OR has the priority for their use. We can refuse to send units in a cooler for areas other tha ER and OR.

[jcdayaz]

I share you view. (Isn't it amazing the we can do all the fancy stuff....Neuroscience ICU, Open Heart Surgeries, etc., but yet not follow rather simple, basic procedures?? It drives me nuts!)

Regarding suggestions: Does your facility have a Risk Management Department, Regulatory Compliance Officer, or something equivalent to Director of Quality Assurance? You might try to work with one of those individuals if you aren't making any progress with the Nursing Directors of the problematic units.

Thanks L106. All departments you mentioned had been contacted at time of my post. Then it became apparent to one of us that an outside governing agency needed to get involved to get any "real" action. If I recall correctly, Joint Commission and CAP were both contacted. Funny how almost immediately the occurance of mis-draws significantly declined!!

[L106]

Congratulations on accomplishing some improvement, jcdayaz. I really don't like to "go over someone's head" (and I don't like it when people go over my head!), but sometimes you feel like it's the only thing left to try. Glad you are seeing improvement!

[angie]

We often give pheresis platelets that contain ABO incompatible plasma to the patient's blood type due to non-availability of ABO compatible platelet inventory. I would not recommend giving a platelet pheresis that contains ABO incompatible plasma to a red cell unit thru the same IV site at the same time, i.e., group "O" pheresis and group A red cells. Anyone else have any comments on that?

We issue only ABO Group specific pheresis platelet at our cardi neuro centre.

[Brenda K Hutson]

Yes, depending on the circumstances. Some possible scenarios that come to mind:

1. For OR (especially if RBCs going in cooler); I have worked places that call it the "cocktail;" platelets, cryo and FFP

Brenda,

Have you had problems with the platelets and cryo being put in the cooler by the OR staff? If so, how did you address them?

My fear is I have NO CLUE what is actually happening to the products after they leave the blood bank. I have heard horror stories of FFP in break room microwaves, etc. Nurses going to lunch break after picking up a unit of blood with the unit in their pocket...etc etc. It can be horrifying!!

I know I can't control everything..but the things I can control I try to do so. "Try" being the operative word here....

I have not had problems in "recent" years of this occuring, however, historically.....abolutely!! And yes, even with bright labels on the platelets stating "DO NOT REFRIGERATE." I am cringing to see some of the scenarios ont his website (not of your Institutions, but of the fact that I have not "heard" of them happening in places I have worked and it is scary to think perhaps they have). Unbelievable!

Brenda Hutson, CLS(ASCP)SBB

[Brenda K Hutson]

We have worked long and hard to build relationships with the Nurse Educators. These Educators do just that - train nurses and perform annual competency training. Transfusion Med: importance of patient ID, reaction recognition and proper handling of components are included in all RN training and competency. We've had few issues since instituting this.

We also have a (mostly) non-punative hospital-wide Incident/Medication error reporting system. The goal is better patient care, not discipline. We are not incident-free, but are doing much more root cause analysis and looking at and fixing our systems.

It takes a while, but it does work.

While I like the "idea" of a non-punitive process, my experience tells me that unfortunately, even working in a field with professionals you often have to resort to ramifications for people to change. I can name a number of such issues even within my own Blood Bank dept. Some staff have great work ethics and they really try to do what is right; for them, a reminder is usually all it takes. Unfortunately, that is not the mindset of all staff. There are some people that I could remind until I am blue in the face and it is not until they are "written up" that I see change.

Same with other areas in the Hospital. I could tell you some real horror stories! Here is just one example where even documentation did not result in change: In 1 Hospital I worked at, we used duplicate copy Transfusion Slips. Once the patient was transfused with the unit, 1 copy of the Unit Transfusion Slip went onto the patients chart and the other copy came back to the Transfusion Service. One day we received 2 units of RBCs back from the OR in a cooler. Upon looking the attached paperwork, the RN had already written down the start time of the transfusion along with the vital signs; problem is, obviously the patient was NOT in fact transfused. They were falsifying the records to save themselves time! I documented this through the Hospital Error Reporting system but the RN only received a slap on the hand. And you guessed it...it happened again; with the same Nurse! The Hospital Compliance Officer left that Facility out of frustration in her inability to affect change to such processes. I left soon thereafter.

Brenda Hutson, CLS(ASCP)SBB

[Brenda K Hutson]

We often give pheresis platelets that contain ABO incompatible plasma to the patient's blood type due to non-availability of ABO compatible platelet inventory. I would not recommend giving a platelet pheresis that contains ABO incompatible plasma to a red cell unit thru the same IV site at the same time, i.e., group "O" pheresis and group A red cells. Anyone else have any comments on that?

Interesting....in the larger Insititutions I have worked at where we kept 30-40 apheresis on the rotator at any one time, we were almost always able to give type specific platelets. However, in the mid-size Hospital I now work at (approx. 400 beds), we only keep 4-5 platelets on the rotator at a time. So, we simply cannot always provide even type compatible for these patients (which has always seemed odd to me; I mean we certainly don't give 2-3 ABO incompatible FFP to a patient so why is it acceptable to give ABO incompatible platelets; and yet it has been in both smaller Institutions I have worked in. It is probably not an issue except perhaps your scenario....something to think about.

Brenda Hutson

[Deny Morlino]

Our pathologist advises us to give type specific with transfusing platelets. Other larger area hospitals do not follow the same advice. I think the situation has a bit to do with differing reasons for the transfusions. The larger hospitals utilize platelets during open heart procedures. Platelets are rarely given repeatedly in this situation. We utilize platelets for oncology populations most of the time. We have frequent repeat visits from the same patients over time. As a result our patients would experience far greater potential exposure to non-group products if we did not abide by our pathologist's advice. Guess we are just a bit conservative.

[adiescast]

I have posted elsewhere my concern about giving such large volumes of incompatible plasma in platelet pheresis units. We would not consider giving out of type plasma to a patient, but no one seems worried about the same volume of out of type plasma from apheresed platelets (except Brenda, below).

Our policy is to give type compatible where possible. Out of type requires a pathologist approval. That being said, even at a large institution it isn't always possible to give type compatible platelets. Maybe that's why the issue has been dormant for so long.