2 blood samples from the patient

[tjohnk1]

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

While it's not my ideal practice, it's what was decided to be the best solution with all the push back from pre-op. Many of our surgicals don't come in until an hour or so before surgery and apparently two collections take up too much time. What I hope happens is that the patient is shown the labeled tube after collection and says "Yep that's my name and DOB" and initials the label.

[Brenda K Hutson]

What are you calling a "barrier identification system?"

Brenda Hutson

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.

[Brenda K Hutson]

Sorry, I asked this same question again. Did not see it until after I asked also.

Brenda Hutson

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).

[L106]

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

Thanks

Thank you

Liz - Sorry, somehow I didn't notice your question until today.

We usually do not have the patient redrawn for a second sample. The "ABO/Rh Recheck" is done by a different tech or by a different method (ie: one ABO/Rh done by automation; the recheck done by tube technique by a tech.) We usually do not have the patient redrawn for a second sample (although I realize that probably provides the best safety.) We do use a separate BB wristband with a unique ID #, so we feel comfortable with our policy.

[ejsommers]

Liz - our confirmation is a non-charge test and it is forward grouping only - ABD. The Rh control is only run on AB+ patients.

[ejsommers]

Hey group - I am curious if CLIA dictates WHO that second draw person should be - i.e. does it have to be a different person than the person first drawing??

[pbaker]

A second type on a second specimen if there is no historical type is mandated by FDA to perform electronic crossmatches. We have a second specimen drawn by a different phlebotomist at a different time. The only exception is more than 12 hours have passed, then the same phlebotomist can draw. The confirmation is not ordered until after the first specimen has been recieved. I have never seen any rules regarding who should draw. I think that is up to each facility.

[Brenda K Hutson]

Ah, see that my recent post on Process Flow for 2nd Specimen was addressed in this Thread last year. Something I would know if I could be on the website more often.

Sorry for the duplication...I am trying to get on more often.

Brenda Hutson, CLS(ASCP)SBB

[Liz]

Hello, since I started his thread I wish to thank all for contributing what you do and what your ideas and propositions are. I wrote the final SOP, it is approved by all concerened factions, and was written after many objected to pricking the patient twice AND one resfused added cost (guess who).

This is it:

a. ................

b. Two individuals shall identify the patient before specimen collection. These two individuals are the person collecting the sample (phlebotomist, Physician or nurse) and an available health care provider (i.e. phlebotomist, Physician or nurse)

c. Upon entering the patient room, the phlebotomist identifies her/himself and states the reason for the visit (e.g. I am Mr. John Smith and I work in the laboratory. Your physician has requested some tests and I am here to collect blood for the tests.)

d. The person collecting the sample shall ask the patient for his/her name in the presence of the other health care provider (phlebotomist, physician or nurse) who will witness the process and confirm that the patient has stated his/her name

e. The two individuals shall check the patient’s bracelet to see if it is compatible with the name given by the patient and with the name on the physician’s request.

f. The two individuals shall document their names (in print) and signature on the request. At this point the witness may leave the room

It goes on, but this is the part about identifyng the patient to satisfy that CAP checklist question.

[Liz]

Please note that this applies to all patients.... to avoid confusion and save time, no need to check if the patient has a history with us, at this point. And it adds to patient safety (even if you think it is not needed, believe me it may be).

[Mabel Adams]

Liz, I assume you have an additional identifier in case you have two John Smiths and also a plan for when the patient can't verify his name.

We use DOB but we have found a time bomb in our patient data base--a set of teenage male twins with the exact same names and DOBs except one is "the third" and the other is "the fourth"--Dad is "the second" with the same name but a different DOB. Pray they are never in a car wreck together! At least I hope they are identical twins and have the same blood type.

No one in the US requires a second specimen specifically for electronic xm that I know of, although a second type is required either on record or it can be on the same specimen. Logic says it is best on a separate draw. CAP is now requiring a second specimen (or something equivalent last I knew) but that is not about electronic xm.

CLIA doesn't address it--those regs are from 1988 so the electronic xm had not been invented and no one was yet talking about second specimens. There were barely any BB computers in 1988. Patient wristbands were made on an addressograph.

[Liz]

Hello Mabel,

This is the part about having two people identify the patient. The actual requirement for Patient identification is not in my post.

It includes: two identifiers: the triple name and the patient's unique MPI (case number). Indeed, a patient may be in coma, so we depend on the wrist ID only. In case we have unknowns at the ED it is a whole other scenario. Regarding having patients with the same name, there is an announcement through the Medical Center, and at the Blood Bank we post this occurrence. We still go by the MPI. DOB is of course acceptable.

[Brenda K Hutson]

I am reading this post right now in preparation for a meeting this afternoon regarding a 2nd blood draw. But I am also trying to figure out "how many different systems" one should have in place for safety.

Currently, this is our armband system (very poor): Patients are given a white Hospital armband upon admission. Since they cannot get it until admission, all patients having blood drawn as an Outpatient (so either Pre-Op, or Outpatient Transfusions) are given a red typenex armband (I know; that is NOT using that band as intended; just one of my battles). But on top of that, we are a beta site for a barcode system in which we print barcode labels that are placed on the paperwork attached to blood products; we then have to Issue the products not only in our BB LIS, but in this 2nd system; then the Nurse uses this 2nd system to barcode the label on the paperwork against the patients's armband).

It is crazy! So I am trying to see "how much is enough; and what is critical." The posting I responded to mentions getting rid of the armband once they have this system in place. My first thought was to use the 2nd blood draw and eliminate not only the red typenex armband, but perhaps the barcode system we are trying out (not yet FDA approved). Yet it seems that while the 2nd blood draw will help prevent the wrong patient from being drawn and/or specimens from being labeled with incorrect labels, I am thinking that this does not catch the problem of a unit being transfused to the incorrect patient. So there are 2 different critical issues: obtaining a correct specimen to be more assured that we have typed and screened the right patient, and, using the barcode system to ensure the blood we Issue is not transfused for any other patient.

Anyone else out there with "combo" systems? Would be interested in hearing what others do?

Thanks,

Brenda Hutson

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!

[Brenda K Hutson]

This brings up an issue that is frustrating to me; not only at my current Hospital, but places I have worked previously. That is the issue of STAT Same-Day-OR orders (even when the patient is on the OR schedule). Rather than give OR an "easy" way to get 2 specimens on patients admitted the day of surgery, I would prefer to "try" to use this to enforce the request that the patient be drawn at least 24 hours prior to surgery (though we will extend specimens for up to 10 days on patients not pregnant and/or transfused in 3 mos).

Brenda Hutson

While it's not my ideal practice, it's what was decided to be the best solution with all the push back from pre-op. Many of our surgicals don't come in until an hour or so before surgery and apparently two collections take up too much time. What I hope happens is that the patient is shown the labeled tube after collection and says "Yep that's my name and DOB" and initials the label.

[Brenda K Hutson]

Are you stating that instead of having a 2nd blood draw (at a different time), you are just requiring that 2 different people be in the room to confirm patient identity for those patients with no history; and you then accept that 1 specimen as being accurate? Because I thought the premise of your post had to do with a 2nd, separate blood draw. I am not sure I would feel that having 2 people in the room at the same time, for 1 blood draw, will add that much more protection. But that is just me....

Brenda Hutson

Hello, since I started his thread I wish to thank all for contributing what you do and what your ideas and propositions are. I wrote the final SOP, it is approved by all concerened factions, and was written after many objected to pricking the patient twice AND one resfused added cost (guess who).

This is it:

a. ................

b. Two individuals shall identify the patient before specimen collection. These two individuals are the person collecting the sample (phlebotomist, Physician or nurse) and an available health care provider (i.e. phlebotomist, Physician or nurse)

c. Upon entering the patient room, the phlebotomist identifies her/himself and states the reason for the visit (e.g. I am Mr. John Smith and I work in the laboratory. Your physician has requested some tests and I am here to collect blood for the tests.)

d. The person collecting the sample shall ask the patient for his/her name in the presence of the other health care provider (phlebotomist, physician or nurse) who will witness the process and confirm that the patient has stated his/her name

e. The two individuals shall check the patient’s bracelet to see if it is compatible with the name given by the patient and with the name on the physician’s request.

f. The two individuals shall document their names (in print) and signature on the request. At this point the witness may leave the room

It goes on, but this is the part about identifyng the patient to satisfy that CAP checklist question.

[Mabel Adams]

I have read some statistics somewhere I think (is that vague enough?) that 2 people checking the same info is not usually safer because each tends to assume that the other was really paying attention. Of course, everything depends on buy-in and education of the people doing the procedure. The best can be circumvented if the people don't 'get it' or care. A weak system with very well-trained people convinced of its value sometimes work well.

Brenda's point is well taken, that you need to look at all the places in the process where a deadly failure could occur and try to minimize the risk in all those spots--specimen collection, labeling, testing, labeling blood bags, issuing, blood administration.

[Mabel Adams]

This is something I've had for quite a few years. Not all steps are prone to fatal mistakes but mistakes at any one may contribute.

To get a transfusion right, we must:

1. Admit patient with proper ID.

2. Order testing on the right patient.

3. Draw right specimen from right patient.

4. Label tubes for right patient.

5. Do tests on right sample.

6. Do right tests.

7. Do tests right.

8. Record results for right patient.

9. Select right units.

10. Crossmatch for right patient.

11. Label units right.

12. Request right blood product for right patient and list right destination (pneumatic tube issue).

13. Issue blood on right patient.

14. Issue right product with right paperwork.

15. Send it to right place (pneumatic tube issue).

16. Hang right blood on right patient.

17. Use right equipment and technique.

18. Note signs of reaction.

19. Report reaction promptly to right people.

20. Collect reaction specimen from right patient.

21. Do right tests on right specimen.

22. If detect problem, determine likely consequences and treat patient appropriately.

[Malcolm Needs ☆]

I have read some statistics somewhere I think (is that vague enough?) that 2 people checking the same info is not usually safer because each tends to assume that the other was really paying attention.QUOTE]

I know that the Royal College of Nursing in the UK did a study on this a few years back Mabel, and that was the conclusion they came to.

[Brenda K Hutson]

I totally understand your point regarding "2 people checking the same info is not usually safer because each tends to assume the other was really paying attention." I have been training Techs and Lab Assistants for most of my career (a number of Facilities) and I always discuss with them what I call "Biased Blood Banking." That can take on many forms. I have taught that in my experience, the further down the road of a given process 1 is, the more they "assume" that surely any error would have been caught by now; so they are not as careful. I try to teach that every person; for whatever their part is in a process, should view it as if no one before them looked closely enough; that they must take the time to look carefully at everything. I also teach that in Antibody ID. For example, seeing a Positive Antibody Screen and upon looking at the antigram, deciding what they think it is. Or making an assumption that a positive screen is just due to the known historical antibody. Sometimes, unbelievable though it is, Techs will actually identify the antibody they expect to see; overlooking reactions they should not have. I teach that when I am performing antibody ID, I look at my reactions (GEL or Tube), decide what to grade them, then look at which cell it is and write the result on the panel. Then go back and do the same with every cell tested; not looking for a pattern while reading; not even looking at what cell # you are looking at until you decide what you will call it (just in case you decided ahead of time what it was and are expecting certain cells to be positive).

So, to make a "short story long," I would also emphasize this in training phlebotomists, Nurses, and anesthesiologists about this 2nd blood draw. Doesn't ensure that your valid concern will not occur; but I can only do what I can do.

Thanks for your input!

Brenda Hutson

I have read some statistics somewhere I think (is that vague enough?) that 2 people checking the same info is not usually safer because each tends to assume that the other was really paying attention. Of course, everything depends on buy-in and education of the people doing the procedure. The best can be circumvented if the people don't 'get it' or care. A weak system with very well-trained people convinced of its value sometimes work well.

Brenda's point is well taken, that you need to look at all the places in the process where a deadly failure could occur and try to minimize the risk in all those spots--specimen collection, labeling, testing, labeling blood bags, issuing, blood administration.

[Brenda K Hutson]

Thanks for sending that! I will definately use that in training. It also highlights the fact that while there are many places where something could go wrong (be missed; overlooked; presumed), we also have many opportunities prior to the time the blood is actually flowing through the IV and into the patient, to catch errors. But it means each person (representing each step above) must do their part and make NO assumptions about those that have gone before them.

Brenda Hutson

This is something I've had for quite a few years. Not all steps are prone to fatal mistakes but mistakes at any one may contribute.

To get a transfusion right, we must:

1. Admit patient with proper ID.

2. Order testing on the right patient.

3. Draw right specimen from right patient.

4. Label tubes for right patient.

5. Do tests on right sample.

6. Do right tests.

7. Do tests right.

8. Record results for right patient.

9. Select right units.

10. Crossmatch for right patient.

11. Label units right.

12. Request right blood product for right patient and list right destination (pneumatic tube issue).

13. Issue blood on right patient.

14. Issue right product with right paperwork.

15. Send it to right place (pneumatic tube issue).

16. Hang right blood on right patient.

17. Use right equipment and technique.

18. Note signs of reaction.

19. Report reaction promptly to right people.

20. Collect reaction specimen from right patient.

21. Do right tests on right specimen.

22. If detect problem, determine likely consequences and treat patient appropriately.

[Mabel Adams]

I just talked today to a Typenex rep. They are supposedly coming out with a better, cheaper equivalent of the blood loc device if that is of any appeal. It will have barcoded stickers of the number plus a bunch of other stuff. It's supposed to hit the market in the next month or so.

She said the bag is still not made of kevlar but it is a little tougher to cut than the blood loc ones. They also have a decent looking barcode BB band that I have looked at and might want to change to if I ever get time. Sorry, don't mean to make a sales pitch; just sharing that there are new offerings sometimes worth considering.

[Liz]

I just saw the posts only today. Thanks for the input. The problem is that patients actually refuse a second draw (often an initial one!!!). I must assume that the Nurses and phlebotomists will be responsible.

[hunb]

While it's not my ideal practice, it's what was decided to be the best solution with all the push back from pre-op. Many of our surgicals don't come in until an hour or so before surgery and apparently two collections take up too much time. What I hope happens is that the patient is shown the labeled tube after collection and says "Yep that's my name and DOB" and initials the label.

If you have willing staff in your pre-surgical unit what we do is have them pull a second sample when performing the I.V. start as they are pulling a syringe in most instances anyway to get I-stat results for anesthesia. Food for thought. We do not retype type O individuals and we also do not require the redraw for ER unless we are already redrawing the individual. ER patients are issued O pos or O neg depending on gender/age.

Barr - Blood Bank Coordinator

[DOGLOVER]

We have been having a 2nd sample drawn for about 5 years now. When we receive a specimen for crossmatch the BB tech does a historical record search. If we have no history and the patient types as anything other then O we request a 2nd draw. If there is a specimen in heme or chem that was drawn at a different time and labeled properly (date, time and phlebotomist ID) we will use that. The 2 draws must be more than 15 minutes apart. Pre-op patients who will need crossmatching upon being admitted but the pre-op work is more than 3 days out will have a ABORH confirmation ordered and drawn by the pre-op nurses. We can cancel it if there is history. This system is working well. In the beginning we had a few bumps and were called a few uncomplementary names but everyone got used to it. Our pathologist was the driving force and the docs didn't really want to fuss at him. This holds for the ED as well. The only place that is slightly different is the pediatric ORs. They will draw the 2nd sample once the child is asleep and the courier will bring it and wait while we run it and then take the blood units. We only do a forward type so it is quick.

[profbaud]

We look to see if the patient has had a CBC or another EDTA specimen drawn within the past 3 days and then use that for the retype. It's just to confirm that the right patient and correct typing was done on the original specimen. Most of the time this works because the low H&H triggers the T&S or T&C order. In cases were we can't get a second type [ER or OR] then we set up O Pos or O Neg units. for electronic crossmatching you require 2 types. If you can't get the 2nd draw, we performed a retype on the SAME specimen by a different tech, but I prefer the 2nd draw if at all possible.