ABO Mistypes

[MEG]

Recently my facility ahs had an increased number of ABO mistypes. We have had 10 for the year. For the most part the tech that is responsible for the mistype catches it anywhere from 10 minutes to an hour after. They call the floor to notify that there is a change in results. I have been writing an occurrence for this even if they catch it themselves. My question is am I being to strict? If they catch it themselves should I not write the occurence? What about cGMP? What is an acceptable number of ABO errors? Thanks for any imput you can provide.

[Ajac]

I do not feel you are being too strict. If the results are released to floor, it is too late. Since corrected reports have to be sent, I think you are obligated to document errors and your follow-up. I would be very concerned at the number of these errors. Have you done a route cause analysis? What about retraining with documentation?

I am assuming that no blood products have been issued on these mistyped patients.

[John C. Staley]

I'm curious, does "10 for the year" mean 10 so far this year or 10 since last year at this time?

Personally my feeling is there is no number higher than 0 that is acceptable for ABO mistypes. Don't get me wrong, this does not mean they will not happen, it only means that they are not acceptable and each and everyone needs to be investigated and the root cause discovered. I have always felt that if the mistype was discovered by the person making the error before any result left the department it was much less dire than had it been reported and possibly acted upon. If it has gone out for general consumption then an occurrence report must be filed.

Is there any kind of consistant theme behind the mistypes? Are they technical mistakes or patient identificaton errors or clerical errors? Is it the same staff member making the errors or most of them or is it evenly spread throughout the staff. I would first look at it as a process problem.

[MEG]

I do not feel you are being too strict. If the results are released to floor, it is too late. Since corrected reports have to be sent, I think you are obligated to document errors and your follow-up. I would be very concerned at the number of these errors. Have you done a route cause analysis? What about retraining with documentation?

I am assuming that no blood products have been issued on these mistyped patients.

The ten mistypes that we have are from January of 2010. As far a a root cause goes, I ask every single person what happened, was there something abnormal going on, was it extremely busy? I get answers any where from " that is the way my fingers are used to going to we were busy." Some tech knew as soon as they did it and came and told me; others wait unitl I find the exception report. An occurence at our facility is not disiplinary, it just that we found an error, tracked it, and when over what should have been done. Here is my next question at what number of misytpes does this become disiplinary? For years these things were not occurences and since I have take the tech specialist job I feel that this very important, my staff on the other hand fells that I am being to picky and strict. I hear the quote" I am only human and I am going to make mistakes"

[Malcolm Needs ☆]

The ten mistypes that we have are from January of 2010. As far a a root cause goes, I ask every single person what happened, was there something abnormal going on, was it extremely busy? I get answers any where from " that is the way my fingers are used to going to we were busy." Some tech knew as soon as they did it and came and told me; others wait unitl I find the exception report. An occurence at our facility is not disiplinary, it just that we found an error, tracked it, and when over what should have been done. Here is my next question at what number of misytpes does this become disiplinary? For years these things were not occurences and since I have take the tech specialist job I feel that this very important, my staff on the other hand fells that I am being to picky and strict. I hear the quote" I am only human and I am going to make mistakes"

I agree with John, that the acceptable number of errors as far as ABO is zero (I also agree with him that this is Utopia, and errors will always occur). You are quite definitely NOT too picky by recording every instance; this is called trend analysis, and is a way of finding out if there is an increase in such errors (which, from the way I read your post, there seems to be), but also may, in itself, give you a root cause (or, at least, help in finding a root cause).

Turning to your question about disciplinary action, I would be most taken aback if one of my staff used the "excuse", "that is the way my fingers are used to going to we were busy", as that is absolutely unacceptable.

Each case should, however, involve an investigation (as it seems so to do), but the disciplinary issue should be dealt with on an individual basis. One culpable error is disciplinary. Two errors with a reasonable reason (NOT a reasonable excuse), is not, necessarily, a disciplinary.

[David Saikin]

Remember this, on the CAP surveys only the Blood Bank is held to 100% correct responses (except for ab id's). There is a reason for that. I agree with John and Malcolm, zero tolerance for ABORh mistypes. How many before disciplinary action - start the clock after the 1st one. At a job I once had, HR told us that we could not have a 100% threshold for ABORh typing . . . our response was "how many deaths are acceptable?" There's always jobs a KMart for those that can't cut it in blood bank - you are not being too strict.

[Likewine99]

The self caught, immediate one I think is acceptable as we are all human and make mistkes. You are not being too picky, is that possible in the BB?

John is right, look at the processes but "flying fingers" and heavy workload are not acceptable reasons. From and HR perspective everyone at my place gets one verbal warning, supervisor documents in the file.

Next occurrence becomes a Level I counseling for not following policy and procedure and it progresses on. This is a pt safety concern.

[Lcsmrz]

No ABO/Rh mistyping should be allowed - but they do rarely occur. It's important that you treat them as very serious errors and allow no excuses! Congrats on having a non-punitive QA system that the techs are comfortable using.

I would have immediately determined a root cause for each and modified whatever was necessary to stop them cold, including reassigning techs who couldn't handle the pressure -- Micro is a nice spot for these techs, as is upper management

[Liz]

I fully agree that those who make mistakes should move out of the BB.

Number of mistakes allowed is ZERO.

What do I do is straightforward: If it has been archived or not: Verbal counseling. A repeat mistake: written warning. A tech who repeatedly makes mistakes will be asked to transfer, if s/he refuses they will be asked to resign, if s/he refuses they will be terminated.

On a nicer note: we do not have mistakes because the ABO is repeated before archiving by a second tech, and checked by the supervisor at the time of archiving. I don’t want to terminate anyone as they are hand picked at HR, and during the interview I do all the discouraging that I possibly can. They are most often my previous students and really want to work at the Blood Bank. I am going to carry on here: Is it because we get more visitors from the Medical and Nursing Team and many, many have met their future spouse at the BB...and left us?

Strict now: Yesterday a new 2-month old recruit wrote negative on the IAT request while she knew it was positive and was preparing the panel. Verbal counseling, and shifted to Day duty for one week to be directly under the supervisor’s and my watch.

[Liz]

Remember this, on the CAP surveys only the Blood Bank is held to 100% correct responses (except for ab id's). There is a reason for that. I agree with John and Malcolm, zero tolerance for ABORh mistypes. How many before disciplinary action - start the clock after the 1st one. At a job I once had, HR told us that we could not have a 100% threshold for ABORh typing . . . our response was "how many deaths are acceptable?" There's always jobs a KMart for those that can't cut it in blood bank - you are not being too strict.

Exactly! Goodness, I have given hell to the House and Nursing Staff for mistakes in pt Id that was not carried out at bedside. They are no longer with us, the staff I mean, the patients survived Thank God as it was the same blood group and neg Ab Sc, but I cannot always depend on my lucky star, that is why Zero mistakes are allowed, I perform live-audits 20/month and chart-audits 30/month.

You are very funny, Dave, about KMart! But it is true, no deaths allowed!!

[David Saikin]

I actually worked at a place where they told the techs about the Kmart jobs if they couldn't handle working in the lab.

[Dr. Pepper]

We have a zero tolerance and would go through the same counseling proccess as described by several posters.

I would be very concerned over the number of errors and wonder if sytem changes are needed. Are there adequate system checks in place, such as computer logic to warn you of a misinterpretation or discrepancy with past results, or a policy to only issue group O RBC until a typing has been verified by a second typing on another spec, etc.?

[vilma_mt]

Recently my facility ahs had an increased number of ABO mistypes. We have had 10 for the year. For the most part the tech that is responsible for the mistype catches it anywhere from 10 minutes to an hour after. They call the floor to notify that there is a change in results. I have been writing an occurrence for this even if they catch it themselves. My question is am I being to strict? If they catch it themselves should I not write the occurence? What about cGMP? What is an acceptable number of ABO errors? Thanks for any imput you can provide.

Far too many mistake to ignore, it does not matter who caught the mistake. If it involves only 1 tech I say it's a tech/training issue. If it involved several techs, I suggest looking at your process before another mistake happens worst case involving transfusion. I have observed some techs reading their ABO tubes and then recording their interpretations based on their memory instead of holding the tube in front of them while recording results. I suggest be pro-active and observe each tech's technique and make it part of yearly competency/proficiency.

[AMcCord]

-- Micro is a nice spot for these techs, as is upper management

Evil thought!

[John C. Staley]

If you can not demote you must promote.

That was the matra of a previous employer.

[Barbarakym]

In your process, do you have rechecks by a second tech to verify type?

I have not seen an error in typing that went past the recheck in several years. Even those found at retype are only 1-2 a year for a hospital transfusing 500 units a month.

I feel the best process is one that allows that we are human and catches any mistakes before they leave the blood bank. Any mistake that makes it past the Blood Bank is disceplinary, as it should not happen at all (0 Tolerance). If the same tech was making the mistakes,that is a tech problem. If there are multiple techs involved, I would think process is involved.

I would look at WHAT ELSE they have to do. In some hospitals the Blood Bank tech is ALSO expected to work other departments at the same time, example Hematology and Coag and meet those ER TATs as the same time as doing Type and Cross in blood bank. While doing wet work in Blood Bank they should not be expected to be dividing their attentions and this is a process problem, encouraged by management.

Priorities start at the top.

BKD

[rravkin@aol.com]

Recently my facility ahs had an increased number of ABO mistypes. We have had 10 for the year. For the most part the tech that is responsible for the mistype catches it anywhere from 10 minutes to an hour after. They call the floor to notify that there is a change in results. I have been writing an occurrence for this even if they catch it themselves. My question is am I being to strict? If they catch it themselves should I not write the occurence? What about cGMP? What is an acceptable number of ABO errors? Thanks for any imput you can provide.

Mindy,

I would agree with the other posters that there should be a zero tolerence for ABO/Rh mistypes, however I would also suggest further investigation into the circumstances leading to these mistypes; ie what other testing was occuring at the time, and if anything could have been done differently, this line of questioning will help gain understanding to issues pertaining to Blood Bank irganomics(spelling??) to technical practice and competence. I do not think you are being too strick; you may not be strick enough depending on your findings. Good Luck!!:)

[Eagle Eye]

Oh my!!! 10 for this year ...to me these are too many. Was any transfusion given based on the wrong type? If yes then it is FDA reportable(even if it did not cause patient harm, eg. O pos RBC to A Pos patient).

You did not mention transfusion so my feeling is these are only type and screen orders. The excuses given by your techs are not acceptable at al at my placel.

I am thinking in the same direction as others:

1) if several techs are involved then you must look at the process and make necessary changes or put in enough check and balances.

2) If few techs are involved in these errors then I would say carelessness. At my place if result left blood bank ---first instance occurance report and counseling, second written warning, third written with suspension and fourth termination.

If the tech made one mistake and the blood was transfused and there is a fatality....I do not think we will be able to keep that employee unless ....I do not know if I can save that employee.

[Eoin]

As a Quality Manager, I concur - zero tolerance. You can use a table - error types across the top, tech names down the side. If there is a vertical line on errors of one particular type (i.e. by a number of techs), you have a process fault issue. If there is a horizontal line against one tech, you have a tech problem. Easy to use and follow. I applaud all "No Blame cultures", but remind peorple it is also a "Just Culture" - you won't be disciplined for an unaccustomed lapse, but you are also responsible for your practice, so more than one will be a cause for concern (re-training and recompetency testing for a start). We have a full SOP for disciplinary procedures - Verbal warning, written cause for concern. A second written cause for concern is time for management action on the issue. I agree though that at all costs a RCA needs to be done on all non-conforming work, otherwise you will never get to the bottom of this. Do you have a Quality Manager in your lab? If so, maybe he/she needs to go. This should have been sorted before 10 occurences EVER, not in just a 12 month period.

Good Luck,

Eoin

[MEG]

I would like to thank everyone for all their input.

[John C. Staley]

One last piece of advise, complicating a process NEVER made it better. If you do discover that you have a process problem be very careful how you go about addressing it. Too many checks and balances tends to make people less diligent because they know someone else will always catch any problems.

[Liz]

One last piece of advise, complicating a process NEVER made it better. If you do discover that you have a process problem be very careful how you go about addressing it. Too many checks and balances tends to make people less diligent because they know someone else will always catch any problems.

Hello John, if I may: Actually, when they know they will be checked they are more careful. What I faced was that the second person was not careful as she was sure that it was initially done correctly (and the initial test was erroneously transcribed)!! So after I lectured her everyone is now careful. No one wants to listen to me lecturing in the middle of work.

[John C. Staley]

Liz, you certainly may. Essentially what I was trying to get at was if you have a second check that failed don't automatically think that adding a third, fourth or even fifth layer of checking will solve the probelm. That is often an easy solution on paper which tends to cause far more problems than it solves.

[Liz]

Liz, you certainly may. Essentially what I was trying to get at was if you have a second check that failed don't automatically think that adding a third, fourth or even fifth layer of checking will solve the probelm. That is often an easy solution on paper which tends to cause far more problems than it solves.

I most certainly agree with that!