Witnessing Blood Bank Draws

[Cheryl Richards]

One of our facilities requires that if non-lab personnel draw samples for types and screens, that someone from the lab go to the bedside to witness the draw. Does anyone else do this or have you heard of it?

Thanks!

[Lecia Guill]

I have worked at a facility whose policy was that only Blood Bank TECHS could draw specimens for Blood Bank. I'm sure this came about as the result of a tragic situation.

As hospitals are under more pressure to cut costs, specimen collection is being delegated to non-laboratory personnel more and more. In my experience, this has resulted in both poor specimen quality and an incredible increase in identification errors in general (not necessarily for Blood Bank). To do everything in your power to prevent an ID error, have a very clearly defined labeling policy with as many safeguards built in as possible, and don't allow any deviation from your policy whatsoever. During my tenure with a previous employer, we required a "competent" patient, a family member, or the RN taking care of the patient to sign the Blood Bank card confirming the patient's identify by name and birth date.

[Malcolm Needs ☆]

In the UK, all blood samples are taken by a doctor, nurse or phlebotomist.

I cannot think of any place that requires a member of the Blood Bank staff to either take the sample or be present.

[Brenda K Hutson]

I know there are certain locations in my current Hospital where the Nurses frequently draw the blood (i.e. from a line in ICU) but I believe a Phlebotomist is there at the time. In Labor and Delivery, I don't think a Phlebotomist is there on those occasssions when a Nurse draws the blood. Unfortunately, a position that our Phlebotomists are frequently put in (but which they are not supposed to allow), is to watch the Nurse draw the blood, then the Nurse hands off the specimens to a Phlebotomist to label. Though the Phlebomists have been told many times not to allow this, I think they get bullied sometimes by Nursing.

When Nursing draws (and labels) specimens, we are more likely to have errors (IV fluid diluted specimen; mislabeled; wrong patient). These are usually caught due to differences in Lab values from previous, and/or different blood types. Not good!

I have much stricter requirements for the Blood Bank Specimens than those overseeing other areas of the Lab do. It never cease to be surprised at the "variations on a theme" of types of errors they can make (not usually wrong patient; usually labeling issues) and their desire to make corrections and/or additions to a labeled specimen. In 26 years and 6 Institutions, I have seen a lot and learned a lot. Therefore, I do not deviate from the requirements for specimens for the Blood Bank. An Outpatient Oncology Facility that we service, has its own lab. They hand-write the information on the specimens and it is often illegible, incomplete and/or inaccurate (all reasons the AABB Standards uses to reject specimens). They are now going to allow only a "select group" of their Phlebotomists to draw blood for the Blood Bank. I am hoping that will cut down on errors and re-draws.

I would not want to switch to Blood Bank staff drawing their own patients, but it seems that no one else understands and/or appreciates our strict labeling requirements/practices. But I still don't want the BB Staff to draw blood.

Brenda Hutson, CLS(ASCP)SBB

[Malcolm Needs ☆]

Just as a matter of interest, in locations where Blood Bank staff draw their own specimens, or have to witness others doing so, what happens in the situation where a patient comes in through Casualty, is bleeding profusely, needs uncross-matched group specific blood STAT, but is not quite at the stage where they need group O RhD+/RhD- to save their lives?

Who takes the sample in such a situation, or do you still have to attend Casualty?

One has to remember, of course, that many labeling mistakes are made in emergency situations, when people think that they have to do everything at breakneck speed, when really, they should be taking their time for the safety of the patient.

[Brenda K Hutson]

I agree that emergency situations can increase the risk of errors (and ironically, those are the exact situations in which I find staff wanting us to be more lenient). I guess in all of my years, my thought is that labeling errors are in large part, due to lack of appreciation by non-Blood Bank Staff (phlebotomists; Nurses) about the potential risks that affect the Blood Bank Dept., more so that other Lab Depts.

Brenda Hutson, CLS(ASCP)SBB

[tbostock]

I agree with Brenda that you cannot allow deviations from the labeling policy. There was a study in 1997 (published in Transfusion journal) that I love to quote:

"The study found that specimens with any obvious labeling error were 40 times more likely to contain WBIT (wrong blood in tube)"

[Malcolm Needs ☆]

I agree that emergency situations can increase the risk of errors (and ironically, those are the exact situations in which I find staff wanting us to be more lenient). I guess in all of my years, my thought is that labeling errors are in large part, due to lack of appreciation by non-Blood Bank Staff (phlebotomists; Nurses) about the potential risks that affect the Blood Bank Dept., more so that other Lab Depts.

Brenda Hutson, CLS(ASCP)SBB

I agree with you about the lack of appreciation Brenda and I also think it is incumbent upon us to do something about it if we possibly can. This could take the form of informal lectures, or a short PowerPoint lecture (with notes) that can be put on the hospital website, or something like that.

I think we have to be careful not to scare the living daylights out of them (keep it pragmatic) otherwise they will think we are going over the top, and the danger then is that they will ignore what we are saying.

[GilTphoto]

We require ALL BB draws to be witnessed. We have a form that must be signed by both the phlebotomist and a witness. Occasionally, a nurse will send down a specimen where only the witness section is signed (I'm a nurse, not a phlebotomist!). Those specimens are rejected. The blood didn't draw itself!

This policy was put in effect to satisfy the requirement to have a plan to reduce misidentification.

[Judy hedglin]

We have two individuals present at all BB draws. It can be any combination of personel except not 2 phelbotomists or LPNs. Med, nurse or lab students are not allowed to participate in the drawing of BB samples.

[Karen Olsen]

We require two people to identify our patients for Transfusion specimen collection. They do not have to be BB staff. We have a detailed 45-60 minute training session for Transfusion collection required by all staff (phleb, nursing, dial,etc) taught by me (BB supv). This has been very effective. We also hand label tubes (UGH) -this has been VERY effective at eliminating misidentification errors.

[Malcolm Needs ☆]

As I said in an earlier post, and as far as I know, within the UK there is no requirement for a Blood Bank staff member to be present when a sample is drawn, but I wonder if we could learn something here.

I know of an incident at a large London Teaching Hospital (that, for obvious reason, will remain nameless) where a sample of blood was drawn on the ward on a Mrs X. This sample was group A, D Positive. For some reason (maybe fate) the Blood Bank telephoned the referring hospital's Blood Bank to ask about the lady. They had made her group O, D Negative.

Obviously, a mistake had been made somewhere.

Another sample was requested, but, upon receipt, it too grouped as A, D Positive.

Then a third sample arrived, and this time it was grouped as O, D Negative!

The Blood Bank Manager went up to the ward and decided to watch as yet another sample was drawn. This typed as O, D Negative.

It turned out that the phlebotomist had asked one of the patients if she was Mrs X. Unfortunately, this particular patient was a little confused, and answered in the affirmative. No other checks were performed.

When the second sample was requested, the same phlebotomist went straight to the same confused patient and bled her again, with no checking at all this time, as the phlebotomist "already knew that she was Mrs X".

The third (correct) sample had been taken by the doctor.

The telephone call had save a group O, D Negative lady being transfused with group A, D Positive blood!

What happened to the phlebotomist? Was she sacked for not following the strict protocol?

No, she was "re-trained" and, as far as I know, is still out there somewhere.

:eek::eek::eek:

[schorj]

Four years ago we switched our hospital policy to having two people being present at the drawing of a blood bank type&screen specimen. One of those people had to be a lab phlebotomist. One person would draw the specimen and the other would be a witness to the draw to make sure that the specimen label info on the tube matched the patient's wristband. Both people would sign on the specimen label. Two exceptions were for specimens drawn in the OR and in labor and delivery. In those areas, two people had to draw and witness the draw, but a phlebotomist does not need to be present.

We went to this policy because in a period of three months we had four T&S specimens, all nurse draws, which were either drawn on the wrong patient or mislabeled. Fortunately, in each case, we had the patient's blood type "on file" so we knew that something was wrong and patient care was not compromised. Since we went to this policy, we have not had any mislabeled or misdrawn specimens that we are aware of.

We are a large hospital with a level 1 trauma service, OH service and bone marrow transplant service. There was a concern when we first went to this policy, that the drawing of the specimen would be delayed because of the phleb witness requirement, but that hasn't been the case. We did say that O uncrossmatched red cells would be available in a life threatening situation, where the draw was delayed. This has only happened once or twice in the four years we have used this policy.

[L106]

Four Type & Screen specimens drawn from the wrong patient or mislabeled is disgusting! Makes you feels really confident about them dispensing medications, doesn't it?

Don't get me wrong, schorj...I am not criticising you or your department.....We see a lot of labeling errors at our institution (usually spelling and minor ID number problems), and I bet (and hope) that it was just a quirk that you observed so many errors in a brief period. But what aggrevates me the "Whoops, sorry!" attitude about the errors. I've got a very clear idea of what would happen to me (or my staff) if we made four errors in three months of issuing the wrong blood to patients or other serious errors.

[Cheryl Richards]

Thanks for all the great responses!. Now, for those who require witnessing, do you also obtain a second specimen from a patient for whom you have no historical ABO RH result? Or do you transfuse based on a result from a solo draw?

[AMcCord]

We have very few draws that are not done by one of our phelbotomists and they are specifically checked off for Blood Bank draws by me or the phelbotomy supervisor (a tech), who is well versed in Blood Bank collections. If the specimen is a line draw (ER, ICU, NSY, ONC etc) then the phleb has to be present to ID the patient and observe the collection. The phleb receives the specimen and labels the tube (remember that they ID'd the patient prior to collection and were present throughout the process).

We have only a few specimens drawn in SURG by anesthesia. We require that the tubes come out of the OR labeled, though we sometimes have to get pretty pushy. We may not get EXACTLY what we require of phleb drawn specimens, but we get enough (name, MR#, time, who drew) or they are rejected. We tell them the patient gets uncrossmatched type O that the surgeon has to sign for until we are happy with the sample. That usually makes things happen. I have met with the anesthia department to explain our requirements and when they understood that these were based on standards, not my whims, they were cooperative. They forget requirements sometimes because they draw so few and there are always new people coming in, but they make aneffort. Our phlebs go into delivery rooms and draw any specimens needed there, but this is not often. All of the OB patients are supposed to be drawn for Blood Bank when a CBC is drawn prior to their spinal.

[GilTphoto]

witness statement and solo draw. This was OK with our last AABB/CAP inspection 2 years ago. Have another inspection coming up in a few months!

I think second ABO is necessary if doing Electronic Crossmatch?