2 blood samples from the patient

[Liz]

When we have a new patient it is required to draw 2 samples for the blood group.

How do you streamline this?

Thanks

[rravkin@aol.com]

Liz,

We can obtain the second specimen from a different draw time within the current addmission if one is available. Otherwise, we have a second specimen drawn. We also do not require this for ER or PAT specimens. What is required always is full patient name, an non-changing medical record number, date and time of draw, signature of the phlebotomist, and a witness signature.

[Liz]

When you have a second blood sample drawn, who draws it, and who drew the first one? and how does the patient react to 2 draws? and who writes the order for 2 draws? who checks that this patient has or doesnt have an archived blood group?

Lots of questions, its pretty much the procedure... do you have it pleeeeeeeeeese??

[Liz]

The point is that I am looking for a procedure that works until we acquire barcode readers, Goodness knows when.

In the meantime, we have a phlebotomy team who draws 5 times a day. The nurses are not allowed to draw and the House Staff do draw but dont want to. So who should perform the 2 draws? the resident first or the phlebotomist, and who checks for an archived Blood group. I want to do it right and write-up a near fool-proof step by step procedure the first time. I am concerned mainly about patients who are newly admitted and require transfusion that is not an emergency so not an emergency release , if I leave it loose, the night shift will end up doing all the work, the transfusion will take place at night (a no no) and the patient and doctors will be screaming about the delay.

Thanks

[Liz]

Moreover, is the second blood group run fully ie forward and reverse, I suppose so, just checking.

[bduff]

We will require this when we go to electronic crossmatch and this is how I understand we will be doing it. The first draw is done by a nurse or phlebotomist. The second draw would be done by a phlebotomist. Usually, from what my supervisor says, they will be having a CBC done again before transfusion if it isn't emergent (from her experience). We would issue O cells until the type is able to be confirmed by forward and reverse if we are unable to get a second specimen. It would be my assumption that this will usually be done when the patient first gets to the hospital and at that point they are too tired of being stuck and less likely to complain. The blood bank tech is the one who looks to see if there is history on file and if it matches the current sample. The blood bank would also be the ones adding on the type confirmation test. I hope this helps.

Brenda

[Byfaith]

We will require this when we go to electronic crossmatch and this is how I understand we will be doing it. The first draw is done by a nurse or phlebotomist. The second draw would be done by a phlebotomist. Usually, from what my supervisor says, they will be having a CBC done again before transfusion if it isn't emergent (from her experience). We would issue O cells until the type is able to be confirmed by forward and reverse if we are unable to get a second specimen. It would be my assumption that this will usually be done when the patient first gets to the hospital and at that point they are too tired of being stuck and less likely to complain. The blood bank tech is the one who looks to see if there is history on file and if it matches the current sample. The blood bank would also be the ones adding on the type confirmation test. I hope this helps.

Brenda

Our policy is similar...Blood Bank tech initiates the process, actually our computer system asks a default question with every blood type "Previous type found?". If no, then a Re-type is automatically ordered with a new accession #. We then check to see if we can use a different specimen on hand which was drawn at a different time by a different phlebotomist (usually a CBC specimen, which we keep for 3 days). If none is found a phlebotomist is dispatched to draw ASAP - if it must be a nurse draw then a phlebotomist may witness. For us, this includes the ER as they are especially culpable for mislabeling errors! If time does not permit, we use type O until a 2nd specimen is drawn. Patients with PAT testing have the Re-Type test deleted, as most have a 2nd sample drawn upon admission. Our computer also alerts us if a second type has not been performed when we get to the crossmatch step.

[David Saikin]

we use a barrier identification system which does not (I think) require a 2nd sample. If/when we do e-crossmatch, a second type from a new sample will be necessary.

[Liz]

Thank you for the very helpful detailed re[plies Ron, Dave, Byfaith and bduff. I shall try having the doctor initiate the process.

Thank you

Oh what kind of barrier do you have Dave? A barcode reader?

[Liz]

Just to make sure: its a full forward and reverse ABO Blood group + D right? Not just a coinfirmatory forward.

Thanks

[Dr. Pepper]

When answering a blood type in our computer, it's easy to see if the patient has been typed before because if so the type is displayed in orange at the top of the screen. We have a "test" (for lab eyes only) attached to our typing test battery called "ABO Group Verified?" which gets resulted as "ABO Verfied" or "1st Type, Use O RBC" (we will change this answer to ABO verified when we do so). We will use other lab specs from a different draw time for the second, verifying typing if need be. So most of the inpatients are either frequent fliers that we've done before or have another lab spec we can use and don't need to be redrawn. About half our ED patients don't have a previous typing. These we ask to be drawn again if need be and if time permits, otherwise we use group O RBC. This doesn't happen that often. About half of our preop patients are first-timers as well. If they have just a type and screen ordered we don't bother retyping because they're probably not going to need blood anyway - if so we'd use group O. Preop patients for bloodier cases who have crossmatches ordered get redrawn for the verifying typing if need be the morning of surgery when they come in. We send a list to the OR every afternoon indicating the patients for the next day who need a retype drawn or a repeat type and screen because they have a history of recent pregnancy/transfusion and their old spec is past the magic 3 day window.

We have some custom-made small red stickers that say "Verify ABO" that go on the "first-time typing" tubes as a reminder to all to verify the ABO if crossmatching other than O RBC. We also put them on the top of our first-timers' preop crossmatch forms as a reminder to check that a retype has actually been done before issuing the blood.

It works for us. We don't have to use group O for non-Os that often. And since I'm the QA guy for our lab, and see all the mis-ID incidents from all the lab depts, and know that the ones you catch are the tip of an iceberg of unknown size...........I sleep better at night since we adopted the 2 typing rule.

[bduff]

Yes a full forward and reverse for us.

[L106]

For the "recheck" testing, we routinely do only the ABO forward grouping and the Rh and Rh Control.

[David Saikin]

Liz

I use the BloodLoc system. your second type does not have to be a full (front/back) type. You can just have a front type (usually not reimburseable).

[sblanchard]

We do a 2nd abo (ABOCK) on pts with no historical type and that are not type O. We do not redraw type O as we will be transfusing O blood. The standard for risk reduction at this time only speaks to Blood type. We perform the initial type and then determine if a recheck is needed. We order an ABOCK (no charge) and send a 2ml pink top tube and the patient label to the floor. We use the 2ml as nursing tends to want to draw both specimens at the same time so this helps us make sure that the draw was done at a different time. A full type is done. So far the only misdrawn specimens we have found have been the second draw. Still an indication that there are identification/labeling problems.

[Liz]

We do a 2nd abo (ABOCK) on pts with no historical type and that are not type O. We do not redraw type O as we will be transfusing O blood. The standard for risk reduction at this time only speaks to Blood type. We perform the initial type and then determine if a recheck is needed. We order an ABOCK (no charge) and send a 2ml pink top tube and the patient label to the floor. We use the 2ml as nursing tends to want to draw both specimens at the same time so this helps us make sure that the draw was done at a different time. A full type is done. So far the only misdrawn specimens we have found have been the second draw. Still an indication that there are identification/labeling problems.

Smart move!!!

[Liz]

Thank you all!!

Dr. Pepper thank you for the detailed steps and various scenarios.

I hope to have the nursing unit and house Staff check if this is a new patient and initiate the process, to alleviate this from the BB Staff.

So a full ABO and Rh as if its a new sample.

Donna by recheck do you mean the new sample, or recheck on the same sample?

Thanks

Thank you

[Byfaith]

Yes, that is what we do.

[tcoyle]

Our policy is similar...Blood Bank tech initiates the process, actually our computer system asks a default question with every blood type "Previous type found?". If no, then a Re-type is automatically ordered with a new accession #. We then check to see if we can use a different specimen on hand which was drawn at a different time by a different phlebotomist (usually a CBC specimen, which we keep for 3 days). If none is found a phlebotomist is dispatched to draw ASAP - if it must be a nurse draw then a phlebotomist may witness. For us, this includes the ER as they are especially culpable for mislabeling errors! If time does not permit, we use type O until a 2nd specimen is drawn. Patients with PAT testing have the Re-Type test deleted, as most have a 2nd sample drawn upon admission. Our computer also alerts us if a second type has not been performed when we get to the crossmatch step.

What computer system are you using that does the auto ordering?

[DOGLOVER]

We just do a confirmatory forward type at no charge. Blood Bank initiates the order when we find we have no historical type (or if the patient is group O we don't require it). If there is another sample in the lab from a different time we can use that otherwise we tell the nursing unit or OR that a confirmation must be drawn. Lots of complaints at first but now everyone is pretty used to it even the pediatric hospital. Nursing does the majority of draws at our facility.

[Byfaith]

What computer system are you using that does the auto ordering?

We have Cerner Millenium

[Susan.Sullivan]

We have used a "confirm type" protocol for almost 2 years. We do not have electronic crossmatch (yet), but implemented the verification type following a FMEA at an affiliated hospital. The process is pretty simple: a second phlebotomy enounter is required for the confirm type. We do not specify who can collect this second specimen, just that it be collected at a time different than the type/cross tube. For PAT specimens, the nursing staff does a fingerstick on the day of the SDC admission. For inpatients they usually have something drawn during their admission that we can grab for a quick type. We do issue type O red cells and AB plasma if a confirm type cannot be obtained. The confirm type is a quick ABO/Rh only (we don't require the backtype). I can share our protocol. We have great compliance, and are so confident we will soon look to eliminate the bbk wristband.

BTW- when the tech answers the question "Previous blood type on file: Y or N" with a NO response, a confirm type order is generated and added to the next collection batch!

[Liz]

Thank you very much Sue and I would greatly appreciate it if you shared your protocol, my email: ek01@aub.edu.lb

Thank you

Liz

[tjohnk1]

We require two collections OR have the patient initial their tube to confirm their identity before transfusing type specific. We don't require a second draw if the patient is group O. The blood bank initiates all the action and one of our phlebotomists usually goes up to do the second draw.

I'm not sure how patients take it as I'm not out there much but when I think about how deadly a mistake could be I wouldn't have a problem getting drawn twice! Most of the time there is a previous tube we can grab anyway. On the 2nd collection we also only do forward typing to confirm.

[R1R2]

.....OR have the patient initial their tube to confirm their identity before transfusing type specific.

This seems inappropriate. Is the patient trained in proper phlebotomy practices and aware of the risk of incompatible blood before initialing the tube?