Current cap inspection

[Brenda K Hutson]

CAP is here today (official CAP Inspectors, not peer review:eek:). One issue was brought up in the Transfusion Service that has been discussed in previous Threads. That is the issue of patient testing with no history at your Institution:

1. Do you have the same Tech. type the same specimen twice (bare minimum to potentially catch a

mistype)

2. Do you have 2 different Techs. drawn the same specimen (will hopefully catch a mistype, but not a

draw of the wrong patient)

3. Have 2 specimens drawn at different times (can allow it to be same phlebotomist, or require that it

be 2 different phlebotomists)

This Inspector is saying that you MUST either have 2 separate specimens drawn, or utilize some type of electronic system (i.e. barcoded armband/blood component/etc). I know of a lot of Hospitals that do you utilize either of these so I am not under the impression that they are required. We currently use barcoded armbands, but when I move towards Electronic XM at the end of this year, my goal was already to obtain 2 draws at different times (plus I know that is the trend).

Just FYI....

Brenda Hutson, CLS(ASCP)SBB

[adiescast]

We do two draws at different times. CAP does NOT require this (see TRM.40670).

[Brenda K Hutson]

We do two draws at different times. CAP does NOT require this (see TRM.40670).

This is where he is coming from. He also emphasized that the information in italics below a bold Question must also be addressed. Anyway, it will not be a deficiency for us because we use the barcode scanners. Actually, I encouraged him to discuss the issue of 2 separate draws in the closing meeting (will just be a recommendation he said) in that since coming to my current Hospital a few years ago, I have had to fight 1 battle after another with the Inpatient and Outpatient Phlebotomy Managers (who clearly have a lack of knowledge of Blood Bank regulations and/or Standard of Practice). Since I was already planning to broach the subject because I want to switch (especially before elctronic XM), him brining it up for discussion may save me some headaches.

Brenda Hutson

TRM.30575

Phase I

N/A YES NO

Does the facility have a plan to implement a system to reduce the risk of mistransfusion for non-emergent red cell transfusions?

NOTE: Mistransfusion occurs from misidentification of the intended recipient at the time of collection of the pretransfusion testing sample, during laboratory testing and preparation of units to be issued, and at the time of transfusion. Misidentification at sample collection occurs approximately once in every 1,000 samples, and in one in every 12,000 transfusions the recipient receives a unit not intended for or not properly selected for him/her. The laboratory is expected to participate in the development of a plan to reduce these risks through implementation of a risk-reduction system. Among options that might be considered are: (1) Documenting the ABO group of the intended recipient on a second sample collected at a separate phlebotomy (including documentation in the institution's historical record); (2) Utilizing a mechanical barrier system or an electronic identification verification system that ensures that the patient from whom the pretransfusion specimen was collected is the same patient who is about to be transfused. The use of a second manual banding system, while currently acceptable, is probably not as effective as the above two options. Other approaches capable of reducing the risk of mistransfusion may be used. The laboratory should participate in monitoring the effectiveness of the system that it implements.

The laboratory should also consider improvements in procedures and/or educational efforts as part of its program to reduce the risk of mistransfusion.

[adiescast]

I am glad he chose not to cite it. Even in the question you quoted it is not a requirement, just one possible way of reducing mistransfusion. CAP does not require that you choose one of the listed options. You have to show that you have a process in place to address the problem.

[David Saikin]

If you use barcoded arm bands and they use the barcodes on the armband AND the unit of blood, it is considered an electronic identification (besides, it complies with the FDA directive of June 2004 requiring barcoding for all medications) and should pass with no problems. If you get cited, just f/u with CAP and tell them what you do. It should be fine. Don't change anything until CAP central says that what you do does not suffice. The inspectors do not know it all - it is a learning experience for them also. We do not draw a separate specimen and we have passed the last 2 inspections.

[KarenJ]

We require a separate specimen, ideally drawn by a different phlebotomist, but at night that isn't always possible.

[Irene59]

There are several different scenarios in place at our institution.

1.) Utilize electronic system, no second draw necessary (preferred method)

2) If not drawn by the electronic system, require a second draw by any phlebotomist, UNLESS

3) Patient has a previous history where there is a type on file. In this case, a second draw is not needed. Of course this is documented in the results, that the patient has a history.

[L106]

I agree with adiescast and David Saikin.

[Brenda K Hutson]

If you use barcoded arm bands and they use the barcodes on the armband AND the unit of blood, it is considered an electronic identification (besides, it complies with the FDA directive of June 2004 requiring barcoding for all medications) and should pass with no problems. If you get cited, just f/u with CAP and tell them what you do. It should be fine. Don't change anything until CAP central says that what you do does not suffice. The inspectors do not know it all - it is a learning experience for them also. We do not draw a separate specimen and we have passed the last 2 inspections.

The only reason he did not cite us was because of the barcoded armbands; otherwise he would have. He did feel strongly that we should obtain 2 separate specimens once we go to Electronic XM (hopefully by the end of this year). That was actually my intent but given the "fights" I have incurred from the Inpatient and Outpatient Phlebotomy Managers on "any" specimen issues since I came, I figured this would be yet another one; so I actually "asked" the CAP Inspector to mention that in the closing meeting to assist me.

Also, just FYI, this was an "official" CAP Inspector. Last year we hired a "difficult" Manager (and that is putting it nicely). We "unhired" her after a couple of months. She then did to us what she had done to her previous Hospital (which we only found out about later) and had downloaded a lot of documents, e-mails, etc. and sent them to CAP and our State Dept. of Health Services. Thus we had 2 unexpected Inspections. We are fine; the inspection Friday went well, but just wanted to let you all know that this issue of 2 separate draws was from an official CAP Inspector. I know it is the trend, but would have argued the case had we been cited for it.

Brenda

[adiescast]

Wow, I'm sorry you were the victim of a hit and run. I'm glad to hear it came out well. That speaks to your level of "always ready." Congratulations on a job well done!

[David Saikin]

If you are going to the eXM you will have to have 2 types on file. One can be a historical type, so there is no need to have 2 "current" types if there is a historical one. I'm sure you already know this, but your comments made me want to reinforce it.

[LaraT23]

We have two people identify the patient when banding. I use PDC armbands ( not barcoded yet) and in the PB area, two signatures are required for ID. I ask that while one is usually a lab staff person, the other should be the patient's nurse or doctor. This way we are also meeting the requirement of minimizing blood draw volumes. In my opinion, if you wait until the patient is drawn again, what is the point, you have to get the product ready. At times, we are lucky enough to have a previous draw to work from but not always. That is why we do the double ID.

On a second note, I am a CAP inspector, and the standard has notes to guide the interpretation of it.

[Linda0623]

I agree with Lara....We either use historical Blood type as the second or in the event of no history (in patient phlebotomists are trained to look in the computer before going to draw the patient) or in the event of unknown status of prior history,(ambulatory care patients, Emergency OR patients, etc) we use a "double ID process" where the patient's RN and the phlebotomist readback the ID off the Hospital wristband, and check it against the label/requisition. To document that the specimen has either been double ID'd or has history vs. none of the above, my LIS system has a test result space on the TS test nmemonic that the tech MUST answer..."Patient need 2nd Specimen?" If they say yes, there is a rule built that does not allow crossmatches to be ordered on the patient until a 2nd type and screen is ordered, and the question is answered as "NO". For patients that have been double ID'd but have only one blood type on file, the tech will order a reflex test called retype, which a second tech will perform if a crossmatch is ordered. This has been well received by both CAP and AABB......now I realize that someone could fake it and just order a second test (Blood Bank does all the test ordering in the LIS) without getting the second sample, or, could forget to say "yes" if the patient has no prior history, but nothing is 100% foolproof, and at least we have a process that works well assuming good technical integrity and allowing that you can't totally eliminate human error..........

[Brenda K Hutson]

If you are going to the eXM you will have to have 2 types on file. One can be a historical type, so there is no need to have 2 "current" types if there is a historical one. I'm sure you already know this, but your comments made me want to reinforce it.

Yes, I have performed electronic XM at other facilities. We either had 1 historical and 1 current, or 2 different Techs. typed the "same" current specimen. However, that only catches a mistype; not a misdraw. But then that is true regardless of whether you are performing the electronic XM, Immediate Spin XM or AHG XM. As we all know, if the incorrect patient is drawn (or specimen mislabeled, etc. etc), it doesn't matter what we do in the Blood Bank after that.

I "believe" that the trend is towards drawing 2 separate specimens (for new patients); however, I have never heard anyone say it was a requirement at this point (and as I said, he only let us off because of the barcoded armband; which by the way, we only recently started using).

In reference to the "notes" for the standard; that is what he was referring to. I guess that is something else I have learned through the years; people can interpret a lot of these "requirements" differently; even among Inspectors.

As far as the extra time and wanting to have blood ready; yes, that is ideal. That being said, what 1 Institution that I worked at did was have the floor either send the 2nd specimen with the Transporter coming for the blood (then a quick blood type was performed and electronic XM; while the Transporter waited), or the 2nd specimen was sent through the pneumatic tube (as blood was also tubed to the floors). It definitely requires more staff (in both phlebotomy and the Transfusion Service). But I disagree that this means "there is no point." I think the point being patient safety and the attempt to try and optimize that at the level of the most common contributing factor; an accurate specimen on the patient. It really didn't take a lot of time to perform that quick type at the last minute.

I just started this Thread to give you guys a "heads up" about a discussion that took place at my Inspection in that Inspectors "get around." Thanks for your responses.

Brenda