Second specimen when there is no historical Group & Type

[KarenJ]

We built a nonbilled test BTRC blood type recheck.  If the patient is preop we send a form over to surgery informing then that this patient has no history and requires a second specimen.  For any other patient it is the responsibility of the blood banker to be sure we have a second type on file before any blood is issued. There is a prompt in Sunquest for previous history which should cue the blood banker to order the retype.  We will accept a sample from a previous draw if availalble/

[Liz0316]

we perform a ABO recheck on anyone who will be transfused or going to surgery that has no type on file. We use a 2 ml pink top, prefer a different phlebotomist, at a different time. We use Collection manager bar code system for all collections. We do not charge and do not report out to downstream systems.

It has been a difficult implementation but thankfully my medical director will not relent!

[Karrieb61]

I am personally amazed at how many places do a second Type/Rh on the same specimen. That doesn't address the wrong patient being drawn and/or the wrong labels put on tubes. I work now in a small hospital where one set of Blood Bank tubes are drawn with two people in the room and they each initial one of the tubes. This does NOT prevent the wrong identification of a patient so I am hoping to move towards a second "event" for the retype tube. How many wrong-blood-in-tubes leading to a near miss or fatality does an institution need  before they have some better system in place to TRY and ensure that the right blood is in the right tube? Bad publicity costs how many $$$$?

[SMILLER]

I am not sure that there is a foolproof way to make sure that the patient matches the unit being given.  Historical records are not reliable: we have had patients here who were using a friends ID to use their insurance.  Having a redraw for another test is no protection if the patient has been armbanded with soem other patients ID.

 

We know of a big university medical center that has been doing only a retest (by the same tech) on the same specimen in order to satisfy e-crossmatch regulations - they have not had one incident after tens of thousands of typings and transfusions.  Of course they have a very robust blood bank arm-banding system -- as any facility should have!  I think that is much more important than how many times the same test is repeated for a particular patient.

 

Scott

[kate murphy]

We require a separate spec from a separate draw.

We use a small white top, no additive, that is not used for anything else.

The tube is not orderable from supplies by anyone other than the BB.

The BB controls the process. We order an ABORH and send the tube and label to the floor for patients with no history. If it's a floor where phlebotomy draws, we'll page them to draw it. If not (ICU's, PACU..) we'll call as ask them to draw.

We do not use another other spec from any other lab.

We started this several years ago, way before we did EXM.

We wanted the nursing/resident staff to know the process, even though we control it.

Even traumas, there is a process when the 1st spec is delivered, we automatically give them a white top.

We've seen our WBITs drop significantly. Not a large number to start, but much smaller now.

[Malcolm Needs ☆]

Many hospitals in the UK are beginning to do this too Kate; a great idea.

[NYCA]

One of the most important points for drawing a second specimen (for patient's without historical type) is to reduce the risk of misidentification. It should be a second phlebotomy (because you are repeating the identification process). Misidentification Risk Reduction is a CAP requirement (see TRM.30575). Retyping the same specimen by a different Tech won't accomplish this.

[SMILLER]

If the patient's armband is wrong, having another phlebotomist draw the same patient for the same test will not help in patient mis-identification either.  The main point of regulators requiring two ABO/Rh tests, it seems to me, is to catch errors in testing (otherwise, why would they allow repeat testing on the same specimen?)

 

Again, I will say that the best protection from mis-identification of patients and specimens is a BB armbanding and phlebotomy system controlled by the BB. 

 

On the other hand - regulatory wise (in the US anyway) there is this from a FDA guidance document last updated April 2014:

 

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2. Recipent ABO/Rh (D) Type and Interpretation

You should determine a recipient’s ABO and Rh (D) antigens (Ref. 11). You should either perform or maintain a record of a second test, confirming the recipient’s ABO/Rh (D). For example, this second test may be a record of a test performed previously, or a repeat test on a second, separately drawn specimen. Repeating ABO and Rh (D) tests on the same specimen is not recommended, as the major cause of ABO errors is “wrong blood in tube” (WBIT). Performing tests on two separately drawn specimens is preferred, as this lessens the likelihood of errors because specimens have been drawn in error. In certain situations, however, only one specimen may be available for testing, such as in emergencies or when only one sample is received for home transfusion. At those times, repeat testing may be performed on the same specimen, but the repeat test should be performed either by a different technologist or by the same technologist using different reagents.

 

If ABO typing discrepancies exist, you should not rely on a computer crossmatch. This is particularly important if there is mixed field red cell reactivity, missing serum reactivity, or apparent change in blood type following hematopoietic stem cell transplantation. Under those circumstances, your procedures should provide for compatibility testing using serologic crossmatch techniques.

 

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The language here is just short of requiring a separate draw for the repeat testing.  It also DOES make the case that this would help with the "wrong blood in tube' situation!

 

Scott

Edited June 10, 2014 by SMILLER

[Likewine99]

We are almost identical to hillDi.  Use Che/Hem samples when available, probably 90% of the time.  No charge for the second type, it is considered "regulatory".  

 

Would use group O if we couldn't get a second type.  

[CMCDCHI]

We allow the retesting on the same specimen, but as SMILLER said, we have a robust armband requirement.  

It seems that there is a large blood management push in the industry right now.  For those of you that transfuse group O until you get that 2nd specimen, how many group O do you think go to non-O individuals because of this rule?  We try to keep very tight control on who gets group O RBCs.  

[Dansket]

We don't require a specimen from a second venipuncture to confirm patients with no history who initially type as group O in Gel.  We retest the specimen with anti-A,B by the immediate-spin tube test.

 

The request for a second specimen is initiated immediately after the results of the anti-A,B test are entered into Meditech.  Meditech reflexes a test CONFIRM that automatically prints specimen collection labels in phlebotomy.  All this happens while the specimen is being initially centrifuged.  Type and Screen takes 35-45 minutes.  It is rare that we haven't received the second specimen before the Type and Screen is done.

[kirkaw]

Scott, I could not find the guidance you mentioned. Is it referring to a 2nd specimen for testing when employing the electronic crossmatch or the use of a 2nd specimen for any person who does not have a historical record in the BB/TS, regardless of transfusion orders?

Thanks, Amelia

[SMILLER]

Here is the URL:

 

http://www.fda.gov/biologicsbloodvaccines/guidancecomplianceregulatoryinformation/guidances/blood/ucm252829.htm

 

Yes, this section is talking about all things e-crossmatch.  If there is any situation where one would be required to have a second specimen for testing verification, certainly that would be in a Lab that does e-crossmatches.

 

But although the FDA strongly suggests a second specimen when doing these, it does not require it.  On the other hand, in the particular section I cited in my previous post, it does go on and on about "wrong blood in tube" errors and how a second specimen can help avoid these types of errors.

 

Scott

[kirkaw]

Thanks for the link and explanation, Scott. That helped a lot!

[tbostock]

 

We allow the retesting on the same specimen, but as SMILLER said, we have a robust armband requirement.  

It seems that there is a large blood management push in the industry right now.  For those of you that transfuse group O until you get that 2nd specimen, how many group O do you think go to non-O individuals because of this rule?  We try to keep very tight control on who gets group O RBCs.

We transfuse type O if we don't have a 2nd specimen yet, but it is faily infrequent (couple times a week). We also have a very active blood management program here, but feel that in this case, patient safety is worth it. We have had some WBIT here, mostly drawn by ED and OR staff. Which is the reason that we always use a second specimen, drawn by our phlebotomy staff. I would recommend discontinuing the practice of retyping the same specimen for all the reasons stated above.