OK, on to bigger and better controversies

[Brenda K Hutson]

Thanks to so many of you for your input to my question about sharing records when you purchase a new Hospital (which opens this Sunday, and NO, we did not get their records).

Next question: Again, with 26 years and 6 Institutions, I can be a stickler (but at the same time, usually have a good pulse for the standard of practice). Our current issue of discussion at my Hospital has to do with specimen labeling; what is required and what is acceptable (to me, they are one and the same). In my experience, it is not uncommon for the Blood Bank to have stricter specimen labeling policies than other areas of the Lab; however our QA coordinator is stating that what is acceptable for one dept., should be acceptable for all depts.; OK, that's fine with me then, as long as all other depts.have my standards )!

I go strictly with the AABB Regulation 5.11.2.3; in summary, we should only accept what is complete, accurate and legible.

So, when I quote that, I am then told that "complete" is relative; that is is just a guideline.

One last insert before I state "my" requirements: I know that some places who use Red Armbands for BB draws, allow the Red Armband# to be 1 of the 2 unique identifiers. I spoke previously with both an FDA and AABB Inspector regarding this in that "my" feeling is that a number that is just stuck to a tube, does not "uniquely identify a person." If I call another Hospital and say I have their patient and want to know their antibody history, they are not going to ask, "Ok, what is their red armband#?!" The Inspectors I spoke to, agreed with that (though I see the Technical Manual lists it as a possible identifyer; so this is just my bias).

I want FULL Name (to be complete), and FULL MR# or D.O.B. as the 2nd identifier. I recently took a specimen back to phlebotomy, noting that the complete name was not there; they said it was; I said it was missing the last letter; I won't repeat what they said......

How about all of you; what are your thoughts/biasis/requirements for specimen labeling for the Transfusion Service.

Thanks!

Brenda Hutson, CLS(ASCP)SBB

[L106]

Ok, here we go....

1. The QA coordinator wants labeling to be the same for all departments. So, if Pathology/Histology demands that a biopsy specimen be labeled with the site ("right great toe"), does that mean that a blood specimen must be labeled with the site ("left antecubital vein")?? (I really like your conclusion, Brenda ......"That's fine, as long as everybody follows MY standards!"...... One of my philosophies is "If everybody would just do it MY way, the world would be a better place!!!")

2. It is true that the patient's name and birthdate are typically what is used when inquiring/sharing info between hospitals, and the medical records number is also usually used when doing a records check within your own institution. However, I view the AABB Regulation about two identifiers as a safety check that the BB specimen came from the correct patient and that the donor blood is issued to the correct patient. So, in this regard, those special Red Armband numbers can be an excellent identifier (assuming we are talking about the same kind of armband that has unique numbers.)

3. In our policy, I had to be specific about what constitutes the "patient's name." I stated "at least the first and last name". I was a little wishy-washy about the middle name, stating "the patient's middle name is also recommended if the patient goes by their middle name or in cases when the first and last names are very common." (Unfortunately, our patient wristbands are limited to "X" number of characters, so lots of middle names would be truncated.)

Sometimes it's hard for others to understand why we are so picky (until a mix-up with "Debra" and "Deborah" causes a patient harm.)

[Malcolm Needs ☆]

IN the UK, the BCSH Guidelines for compatibility procedures (2004) state:

"It is essential that the request form and sample contain the following minimum patient identification (PIN) as described in BCSH Guidelines for the administration of blood and blood components and management of transfused patients (BCSH, 1999).

(i) surname/family name (correctly spelt);

(ii) first name(s) in full;

(iii) date of birth (not age or year of birth);

(iv) hospital number/accident and emergency number/NHS number/major incident number (in certain instances, such as a male partner of a pregnant lady, we will also accept an abbreviated address as an identifier, if none of the other criteria listed in iv are available - MN).

The sample should be dated, labelled and signed by the person taking it. The request form should also include the patient's location and the location where blood units should be sent and the signature of the person making the request....

Provided that sample labels are printed and attached to the bottle next to the patient at the time of phlebotomy, hand-held bedside/chair-side scanners and printers utilizing bar-coded wristbands may increase security during phlebotomy. Labels produced in this way are not the same as addressograph labels, which are more likely to result in inadequate checking of PIN at the bedside (Sharp and Cummings, 2001). It is therefore recommended that any labels preprinted away from the bedside should not be accepted for either grouping or pretransfusion testing samples....

Samples received from trauma or unconcious accident and emergency patients are unlikely to contain the full PIN. There, however, must be at least one unique identifier, usually an accident and emergency or trauma number, and the sex of the patient identified on the sample label. The sample should be taken andlabelled and the form and sample should be signed by the prescribing medical officer as one continuous procedure.

In the event of there not being at least one unique identifier on the sample in a life-threatening situation, group O blood only must be issued until a suitably labelled sample is available. If the patient is a female under 60 years old, group O D-negative blood should be given."

When I was working in a hospital, we stuck rigidly to this guideline.

Now I am working in a Reference Laboratory, many miles from some of our referring hospitals, and where it may be difficult to obtain replacement samples (particularly in an emergency), we may have to work on the samples under a concession form, if the mis-labelling is minor, signed either by one of our own Consultants or, in certain cases, me (as the Reference Service Manager).

As all of our samples come through the hospital Blood Banks before referral to us, it is surprising how many we have to reject, or have to work on under concession!

:rolleyes:

[David Saikin]

I agree with LI06's interpretation . . . we also require the identity of the phlebotomist and the date/time of collection.

[bjwhite]

At our hospital, we use a red armband also. We require that the label from that armband have the patients full first and last name (spelling counts!) and their medical record number, date/time of collection and phlebotomists computer ID. If any of this is missing or wrong, the sample is rejected. Period. If it is an emergent situation, then O neg/pos units are given as uncrossmatched until a proper specimen is received. Our rejection rate is approximately 5% each month. Our biggest nursing unit just started to enforce the policy that if the same staff member has one rejected sample, they are verbally warned, two is a written warning, third is suspension and fourth is termination. I'm hopeful that this helps our rejection rate fall to at least 1-2%. I would really hate to see someone lose their job because of labeling issues, but patient safety has to come first and if tubes for testing are not labeled right, what else are they missing?

[tbostock]

I go strictly with the AABB Regulation 5.11.2.3; in summary, we should only accept what is complete, accurate and legible.

So, when I quote that, I am then told that "complete" is relative; that is is just a guideline.

That's a good one, Brenda. Complete doesn't really mean complete, does it? Jeez....

All of the identifiers on our BB tube (name, MR#, DOB, and red band #) have to be perfect or it is rejected. Date, time and initials are required, but they can come and fix them; not my choice, but it was a decision made since they were not patient identifiers. Our mislabeled rate is 1-5% depending on the day and lack of focus...

[MAGNUM]

Here at my hospital, if it isnt complete, it gets filed in the red filing cabinet and the collector gets to revisit the patient and redraw the specimen. We do use a red armband, but the armband is wide enough to permit use of a hospital label that contains all lthe patient information. I also require the person collecting the specimen to date time and intial the specimen and armband. If they do not match, then filed.

[Brenda K Hutson]

I appreciate you all taking the time to respond. You see, I don't think the problem is in what "items" we believe should be on a specimen, as much as it is in how strictly it is enforced from Institution to Institution. I am trying to have it strictly enforced, but given the history here (accepting incomple names; sending specimens "back" to have the red armband# applied ; sending incompletely labeled cord specimens back for additional labeling; and many more scary things), I am facing an uphill battle and seen as being too rigid. Oh well, on with the battle!

Brenda Hutson, CLS(ASCP)SBB

[Malcolm Needs ☆]

I appreciate you all taking the time to respond. You see, I don't think the problem is in what "items" we believe should be on a specimen, as much as it is in how strictly it is enforced from Institution to Institution. I am trying to have it strictly enforced, but given the history here (accepting incomple names; sending specimens "back" to have the red armband# applied ; sending incompletely labeled cord specimens back for additional labeling; and many more scary things), I am facing an uphill battle and seen as being too rigid. Oh well, on with the battle!

Brenda Hutson, CLS(ASCP)SBB

Brenda, you are not being too rigid; your people sending you incompletely labelled samples are being too lax.

You must stick to your principles, otherwise, one day, whem you do relent and accept a poorly labelled sample (and get sued) it will come back to "bite you on the ***" (if you will excuse the phrase).

More power to your elbow I say, and blow the rest of them; if they can't label samples correctly, that's their problem, not yours.

Edited July 11, 2009 by Malcolm Needs
This may surprise people, but it was spelllllllllling again.

[ovrwkd]

The only acceptable sample is a completely labled sample (labeled at bedside) with unique identifiers.

Full name, id number, date of draw and initials (signature) of person drawing sample.

State and federal (or your country of residence) regulations may add to this such as in Malcolms' id requirements for DOB.

The more info, the better able to trace the sample back to the patient/phlebotomist in event of questions.

I prefer more information like DOB as well. Patients "hospital hop" here.

There should be no difference between BB samples and other department samples. If the standards are the same for all staff, compliance is easier to maintain.

[Malcolm Needs ☆]

The only acceptable sample is a completely labled sample (labeled at bedside) with unique identifiers.

Full name, id number, date of draw and initials (signature) of person drawing sample.

State and federal (or your country of residence) regulations may add to this such as in Malcolms' id requirements for DOB.

The more info, the better able to trace the sample back to the patient/phlebotomist in event of questions.

I prefer more information like DOB as well. Patients "hospital hop" here.

There should be no difference between BB samples and other department samples. If the standards are the same for all staff, compliance is easier to maintain.

ovrwkd, I think that your last sentence hits the nail absolutely on the head.

If our colleagues in other pathology disciplines allow samples that are labelled, frankly, in a sloppy manner, it will encourage those who provide the samples to labelled them in a sloppy manner.

If our colleagues in other pathology disciplines only accepted fully labelled samples, it would encourage those drawing the samples to label fully (and accurately). The drawers would soon get fed up having to do their job twice (not forgetting that they would soon get fed up with the complaints from the patients who are having to be stabbed twice).

[Sko681]

We require 2 unique identifiers which are the patients name (spelled out fully and correctly) the patients Medical Record number and if they are outpatients for transfustion they must also have the patients date of birth. Also, we require the phlebotomists initials, date and time of draw. The only exception to this is the time of draw, if they forget the time of draw we will let it slide if it is a truly urgent situation. Otherwise there are no exceptions, we do not use them and they are redrawn.

After all....you can only be as good and accurate as the specimen you receive!!

[Brenda K Hutson]

Well, I suspect my battle will be more productive if I approach it from the standpoint of the ramifications of improperly/incompletely labeled specimens for the Blood Bank. If I try to include ALL Lab Depts. for a consistent policy (which I do agree with by the way), I suspect I will then lose the battle, as all of the other depts. here are willing to accept "less than perfect" and allow some changes to be made. They will turn it around and use it against me; that if these less than perfect specimens are "good enough for them," then they should be good enough for me. I am not "over" those depts., so that is not my call (and we are talking a faciltiy where most of the staff has been here most of their careers and are very set in their ways).

So, onward...

Brenda Hutson, CLS(ASCP)SBB

[Malcolm Needs ☆]

Good luck Brenda.

I think this was a fine thread to start, and you deserve to "win" in your institution.

More power to your elbow!

[reidhospbb]

As with several others, we use the red armband to assure continuity from the time the specimen is obtained until the unit is hung for that patient. we use computer generated labels on the red armbands and the tubes. The phlebotomists, nurses, aides, etc. that draw the blood must put their initials on the tube along with the date the specimen was obtained. Since we are using positive-patient ID software (scan the armband) I am considering dropping the red armband. The hospital issued patient ID has MR# as well as the DOB and financial number to be used as unique identifiers. The armband is scanned at the time the specimen is obtained. We generally have a 1% or less mislabel rate. Good relations with nursing administration is a must.

[MACWHC]

Brenda, I'm completly on your side with this one. Especially with the "if the rest of the hospital would only do things the blood bank way". At our institution the label prints out of the LAB system and the work is done in the BB system. If a patients name is K. Michael Smith. The LAB system truncates to K.M. Smith.(upgrading soon and this will finally go away - yea!) BB will not accept the specimen unless the rest of Michael has been hand written in at the time of collection. The label must match exactly letter for letter and identifier (MRN or DOB) to identifier to be acceptable.

Stick to your guns on this one!

[shelleyk482]

Here is the abstract from an article in Transfusion (1997, Nov-Dec, 37, pgs1169-1172) that I have used in 3 different facilities to prove that it is extremely important that specimens be labelled totally correctly or they need to be recollected.

Adherence to a strict specimen-labeling policy decreases the incidence of erroneous blood grouping of blood bank specimens

JA Lumadue; JS Boyd; PM Ness Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA.

Copyright

ABSTRACT

BACKGROUND: To assess the effectiveness of a system of preventing incompatible blood transfusions resulting from the misidentification of patient specimens, a prospective analysis of all blood samples submitted to a laboratory was performed. STUDY DESIGN AND METHODS: Incorrectly labeled specimens (rejected samples) were tested for ABO and Rh type, and routine antibody screens were performed. Test results were compared to historic patient data or patient data obtained from subsequently submitted (correctly) labeled specimens. For comparison, all discrepant serologic results from appropriately labeled samples were also recorded. RESULTS: Specimens that failed to meet the criteria for specimen acceptance were 40 times more likely to have a blood grouping discrepancy. CONCLUSION: Strict adherence to the labeling requirements results in a significant decrease in erroneous blood grouping. This would accordingly diminish the likelihood of transfusing out-of-group blood components.

Hope it helps.

[eric1980]

Here is the abstract from an article in Transfusion (1997, Nov-Dec, 37, pgs1169-1172) that I have used in 3 different facilities to prove that it is extremely important that specimens be labelled totally correctly or they need to be recollected.

Adherence to a strict specimen-labeling policy decreases the incidence of erroneous blood grouping of blood bank specimens

JA Lumadue; JS Boyd; PM Ness Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA.

Copyright

ABSTRACT

BACKGROUND: To assess the effectiveness of a system of preventing incompatible blood transfusions resulting from the misidentification of patient specimens, a prospective analysis of all blood samples submitted to a laboratory was performed. STUDY DESIGN AND METHODS: Incorrectly labeled specimens (rejected samples) were tested for ABO and Rh type, and routine antibody screens were performed. Test results were compared to historic patient data or patient data obtained from subsequently submitted (correctly) labeled specimens. For comparison, all discrepant serologic results from appropriately labeled samples were also recorded. RESULTS: Specimens that failed to meet the criteria for specimen acceptance were 40 times more likely to have a blood grouping discrepancy. CONCLUSION: Strict adherence to the labeling requirements results in a significant decrease in erroneous blood grouping. This would accordingly diminish the likelihood of transfusing out-of-group blood components.

Hope it helps.

A seminar I attended early this year had the speaker quoting this article!

Brenda, if the fight is still on, you may want to print that article out to back yourself up.

My hospital uses the patient's identity number AND full name as identifiers.

[BBK710]

Here is the abstract from an article in Transfusion (1997, Nov-Dec, 37, pgs1169-1172) that I have used in 3 different facilities to prove that it is extremely important that specimens be labelled totally correctly or they need to be recollected.

Adherence to a strict specimen-labeling policy decreases the incidence of erroneous blood grouping of blood bank specimens

JA Lumadue; JS Boyd; PM Ness Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA.

Copyright

ABSTRACT

BACKGROUND: To assess the effectiveness of a system of preventing incompatible blood transfusions resulting from the misidentification of patient specimens, a prospective analysis of all blood samples submitted to a laboratory was performed. STUDY DESIGN AND METHODS: Incorrectly labeled specimens (rejected samples) were tested for ABO and Rh type, and routine antibody screens were performed. Test results were compared to historic patient data or patient data obtained from subsequently submitted (correctly) labeled specimens. For comparison, all discrepant serologic results from appropriately labeled samples were also recorded. RESULTS: Specimens that failed to meet the criteria for specimen acceptance were 40 times more likely to have a blood grouping discrepancy. CONCLUSION: Strict adherence to the labeling requirements results in a significant decrease in erroneous blood grouping. This would accordingly diminish the likelihood of transfusing out-of-group blood components.

Hope it helps.

This is also referenced in an article "Two-Specimen Requirement for Verification of ABO/Rh" in the new Transfusion(July 2009 Vol.49,No7 pgs.1321-1328). Interesting reading.

[Brenda K Hutson]

By the way, after reading your responses, I noticed I had not addressed the issue of phlebotomy documentation in my original thread. So yes, in addition to complete First and Last Names, MR# or DOB, and Red Armband (if applicable; we don't use it as intended which is my next battle), and the Date/Time/Initials of person drawing the specimen.

Thanks again for all of your input..

Brenda Hutson, CLS(ASCP)SBB

D

[Brenda K Hutson]

I like your last sentence...

Brenda

[Brenda K Hutson]

We require 2 unique identifiers which are the patients name (spelled out fully and correctly) the patients Medical Record number and if they are outpatients for transfustion they must also have the patients date of birth. Also, we require the phlebotomists initials, date and time of draw. The only exception to this is the time of draw, if they forget the time of draw we will let it slide if it is a truly urgent situation. Otherwise there are no exceptions, we do not use them and they are redrawn.

After all....you can only be as good and accurate as the specimen you receive!!

Hmmm.don't quite have this website figured out yet. I wanted to say that I like your last sentence (but somehow it ended up on an e-mail "all alone" at the end...

Brenda

[Eoin]

Brenda,

Stick to your guns (and all other bloodbankers I suppose).

This same battle rages in all hospitals (in my 40 odd years I have worked in seven). It also depends to a large extent on the size of the hospital and the dedication and training of the phlebotomy team. Our largest problem was with junior doctors out-of-hours, but I finally convinced the CEO and HR to include blood transfusion training requirement by our Haemovigilance Officer or myself (Quality Manager) in their contract. They MUST attend pre-employment (usually when they visit the employment health nurse for the obligatory checks). As the contract is signed off by them, it becomes a legal obligation and we get great attendance at training.

All this doesn't mean we get 100% compliance with specimen labelling, but they do know if they get it wrong, they will be asked to re-draw. Obviously we have the urgent scenario in our SOPs (doesn't do to let a patient exanguinate), but we don't tell them that, and blood is released with a disclaimer, with the error clearly delineated (Onus is on attending consultant for the use of this unit because ------------------) Dated, Timed and Signed by the Medical Scientist (plus name in Block letters plus contact details).

We will never live in an error free world, but to not expect and accept at least the minimum standards, could be catastrophic for the patient plus all concerned. During education, we tell them that this strict adherence is for their own benefit as much as the patient.

Cheers to all

Eoin

[eric1980]

Brenda,

Stick to your guns (and all other bloodbankers I suppose).

This same battle rages in all hospitals (in my 40 odd years I have worked in seven). It also depends to a large extent on the size of the hospital and the dedication and training of the phlebotomy team. Our largest problem was with junior doctors out-of-hours, but I finally convinced the CEO and HR to include blood transfusion training requirement by our Haemovigilance Officer or myself (Quality Manager) in their contract. They MUST attend pre-employment (usually when they visit the employment health nurse for the obligatory checks). As the contract is signed off by them, it becomes a legal obligation and we get great attendance at training.

All this doesn't mean we get 100% compliance with specimen labelling, but they do know if they get it wrong, they will be asked to re-draw. Obviously we have the urgent scenario in our SOPs (doesn't do to let a patient exanguinate), but we don't tell them that, and blood is released with a disclaimer, with the error clearly delineated (Onus is on attending consultant for the use of this unit because ------------------) Dated, Timed and Signed by the Medical Scientist (plus name in Block letters plus contact details).

We will never live in an error free world, but to not expect and accept at least the minimum standards, could be catastrophic for the patient plus all concerned. During education, we tell them that this strict adherence is for their own benefit as much as the patient.

Cheers to all

Eoin

We are looking at a victorious general here.

Eoin, it must have taken a lot to convince your top management to make new doctors attend your obligatory training. We do not have that in my hospital, and so we do have such errors now and then.

How long did you take to prepare and convince them?

[Eoin]

Eric,

Took some time nibbling away. The best mover was a retrospective lookback at form/specimen/identity issues (We keep sheets in the labfor that purpose) - by far the biggest outliers were junior docs. That plus selected readings from surveilance reports and the feedback from SHOT meetings (where it is a problem with all delegates), a resolve to do something about it, a supportive Hospital Transfusion Committee and the consultant who is joint director of the BT service in the hospital. Good luck with it.

Regards

Eoin