2 blood samples from the patient

[Liz]

......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.

This does not fulfil the CAP requirement, it really does not confirm that it is from the correct patient.

[Liz]

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.

If you remember, can you send the reference please.

[Liz]

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.

Malcolm, do you have the reference please?

[Malcolm Needs ☆]

Hi Liz,

Apparently, this was a recommendation that came out in the Severe Hazards of Transfusion (SHOT) Report last week at their meeting (I say apparently, because I wasn't there), but I'll see if I can get the exact quotation. Unfortunately, my Deputy (who did go, and has got the report) is on leave today.

[Liz]

ok thanks, I shall wait...

[Malcolm Needs ☆]

Right then!

In the BCSH Guidelines of 1999 (BSCH Blood Transfusion Task Force. The administration of blood and blood components and the management of transfused patients. Transfusion Medicine, 1999; 9: 227-238), on page 231, it states:

"The bedside check is a vital step in preventing transfusion error, and staff must be vigilant in checking the patient's identification details match those on the transfusion report form, and the compatibility label attached to the blood pack. This procedure has traditionally involved two members of staff, with at least one being a qualified nurse or doctor. However, this is a controversial area, and it has been argued that one responsible member of staff would more reliably carry out the procedure than two (Linden J, Kaplan H. Transfusion errors: causes and effects. Transfusion Medicine Reviews 1994; 8: 169-183). Two members of staff may rely upon the other to be rigorous, resulting in neither giving the task their full attention.

It is recommended that one member of staff should be responsible for carrying out the identity check of the patient and the unit of blood at the patient's bedside. The member of staff must be a doctor, or a nurse holding current registration of the UKCC Professional Register as a Registered General Nurse (RGN), Registered Sick Children's Nurse (RSCN) or Registerd Midwife RM)."

These Guidelines have, however, been superceded (BCSH. Guideline on the Administration of Blood Components, published in 2009, and available on the BCSH website) and on page 35 of this document (tome!!!!) it states,

"14.3 one or two person checks

• A systematic review (Watson D, Murdock J, Doree C, Murphy M, Roberts M, Blest A, Brunskill S. Blood transfusion administration - 1 or 2 person checks, which is the safest method? Transfusion 2008; 48(4): 783-789) found no unequivocal evidence to support either a one or two person checking procedure.
  
• As a minimum, one registerd healthcare professional, comptency assessed to NPSA SPN 14 (2006) standards (or for Scotland to the NHS QIS (2006) Clinical Standards for Blood Transfusion) (I have NO idea what are either of these! MN) must perform the checking/administration procedure.
  
• Organisations should risk assess their checking procedures.
  
• If local policy requires a two person checking procedure, each person should complete all the checks independently (double independent checking)."
  

The thing I was talking about at the SHOT Meeting was a poster (which, incidentally, one the prize for the best poster):

Daniels H, Stewart P, Paterson P. Can one head be better than two? (Single nurse administration for blood components). Annual SHOT Symposium 2011, Abstracts accepted for Poster Presentation.

Their conclusion was that one is better than two - and the nurses agree with them.

I'm not sure where you can get a copy of this.

I hope that helps.

Malcolm

:whew::whew:

[Brenda K Hutson]

My apologies ahead of time for the length of this e-mail......

So we just had our first meeting to discuss the implementation. I think we came up with more issues (mostly created by ourselves) than we did solutions at this point (you know that saying; too many cooks in the kitchen; and some of them really belong in the bathroom....ok, I digress).

First, let me add a comment based on what I have read in this Thread. There is mention of barcoded armbands. Currently, the Inpatients do have a Hospital armband on with a barcode reader (I am told it is the financial #; but other identifiers still visible on armband also). That is used by phlebotomy. Then the phlebotomy Manager decided to throw a 2nd wrench in the works; another barcode system that is used both in the BB, and on the Nursing Unit. I guess the most important purpose of this is making sure the unit belongs to that patient. Unfortunately though, it is not interfaced with our BB system! So we have to Issue in 2 systems! He chose this 2nd system because it is what the phlebotomists are using to identify patients against specimens. So now it is being extrapolated to identify units against patients. But that also means Nursing has to use 2 systems to process the unit they receive (but this barcode system eliminates the requirement for a 2nd Nurse to check). Problem is, Outpatients don't have that armband; so they get the red typenex armbands. So part of moving to a 2nd blood draw is to eliminate that red armband (and note, the Hospital will not give the Hospital armband to outpatients).

So, we have our internal BB computer system doing checks; we have started this barcode reader system to double-issue; and now we are going to a 2nd blood draw. I say just bring the patient down to the BB, we will draw their blood, test it, then transfuse them right then and there!! THAT would be easier than all of this.

I am totally onboard with added patient safety; but it seems to me we are going way overboard and perhaps doing some processes we don't need to (i.e. duplicating work). Thanks for listening; whining completed. Now on to my questions.....

1. Easy question 1st: does anyone charge for this 2nd blood type? Currently we perform 2 types on the same specimen and the 2nd type is a no-charge confirmation type. However, given that the regulatory agencies are moving towards this 2nd blood draw, just wondering if we can charge for it?

2. A couple of Institutions actually provide the tube to be used by phlebotomy or the Nurse; ensuring they are not "cheating" and sending another specimen that was drawn at the same time as the first; maybe just changing the time. I like that but the phlebotomy manager doesn't. He said that it would be his staff drawing most of those; that sending tubes to Nursing Units would just confuse things and possibly delay that 2nd draw; and that we should be "trusting" whoever draws the 2nd specimen to not play any games like that (well....maybe in a perfect world; but that is not the world I have worked in for 28 years and 6 Institutions).

3. Currently, the Test Results the BB enters go back through the Hospital I.S. and can be viewed by Nurses. 3 years ago after attending Nursing Management Meetings, I convinced them that the Nurses needed to look at blood availability in the Hospital I.S. system; not call us all day asking if blood is ready (is that not what interfacing is for??). And it worked! It will show the Unit #; the Product Type; Status of Ready, Issued or Transfused. So some in the meeting were saying that Nurses would have to look and see if the 2nd type was completed yet; before they sent for blood that said READY (so now READY will not necessarily mean READY). I DON'T THINK SO!! That is just asking for the calls to come in again. I say we need to have a mechanism that alerts the Nurses that we require a 2nd specimen on their patient, even though they may not be drawing it themselves. But then that brings up; how will they know when it has been completed and the blood is in the BB; so they don't call??

4. So, need a simple system (if there is such a thing for this) that does not result in Nurse calls to the BB; or BB calls to the Nursing Units.

Brenda Hutson, CLS(ASCP)SBB

[Mabel Adams]

Can you wait to set up the blood till you get the second specimen typed? Then I assume the computer would not say "ready" until it really was. Or, in emergencies set up group O as others do.

[Liz]

Thank you Malcolm and Brenda for this great information!!

[Malcolm Needs ☆]

You are more than welcome Liz.

[Dr. Pepper]

Brenda, for the easy question #1, we've had the 2nd typing rule in place for several years and we do bill for it. We have not had any problems doing so, probably because 99% of these patients are inpatients and hence fall under DRGs.

[DOGLOVER]

We recently started charging for the 2nd type. What we do for notification is this, first we look to see if there is a suitable specimen available else where in the lab. If there is, we go get it and we're done. If not, we call the patient's nurse and tell her we need one drawn before any blood can be dispensed. (Nursing draws most of the blood in our facility). Also, we actually have caught people playing the game you mentioned of saving the 2nd tube . I think we pretty much have that stopped. The only problem comes when it is a pre-op patient and the patient won't show up again until shortly before surgery. I try to call the OR's in the morning and notify them and also the CV OR transport people have learned to call and ask before they waste a trip to the BB. Then they can just bring the sample with them and while one person signs out the units and gets a cooler ready, someone else does the confirm type(it is only a forward type). We also put a bright pink card on the units that say they need a confirm type so someone will not inadvertantly dispense them. You do have more challenges having to deal with 2 computer systems. I have worked with that situation in the past and it is a nuisance. Can you get your medical director to really push for an interface?

Good luck in the implementation. It won't be as bad as it seems.

[Brenda K Hutson]

That is 1 thing we are considering. However, since we currently perform an Immediate Spin Crossmatch (will eventually move to electronic XM), that is added time they will have to wait. And if we follow some of the protocol used in another place I worked, our 2nd specimen for patients going to surgery, was often when the Transporter came to pick up blood (the 1st specimen being drawn with Pre-Op Lab specimens). So, a lot to consider.

Thanks,

Brenda

Can you wait to set up the blood till you get the second specimen typed? Then I assume the computer would not say "ready" until it really was. Or, in emergencies set up group O as others do.

[Brenda K Hutson]

I'm sorry, still laughing over one of your sentences; specifically, "can you get your medical director to really push for an interface!" Wouldn't that be special! Enough said...

Brenda

We recently started charging for the 2nd type. What we do for notification is this, first we look to see if there is a suitable specimen available else where in the lab. If there is, we go get it and we're done. If not, we call the patient's nurse and tell her we need one drawn before any blood can be dispensed. (Nursing draws most of the blood in our facility). Also, we actually have caught people playing the game you mentioned of saving the 2nd tube . I think we pretty much have that stopped. The only problem comes when it is a pre-op patient and the patient won't show up again until shortly before surgery. I try to call the OR's in the morning and notify them and also the CV OR transport people have learned to call and ask before they waste a trip to the BB. Then they can just bring the sample with them and while one person signs out the units and gets a cooler ready, someone else does the confirm type(it is only a forward type). We also put a bright pink card on the units that say they need a confirm type so someone will not inadvertantly dispense them. You do have more challenges having to deal with 2 computer systems. I have worked with that situation in the past and it is a nuisance. Can you get your medical director to really push for an interface?

Good luck in the implementation. It won't be as bad as it seems.