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Operating Room Risk Reduction Plan for Mistransfusion


ejani

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Our facility is changing the risk reduction plan for mistransfusion.  The plan is to collect a second sample for those who do not have a history in the Blood Bank as recommended by CAP (TRM.30575).  The problem we are encountering is with the Operating Room.  The OR does not want to collect a second specimen for those who do not have an ABO/Rh on file.  They are adamant they will draw from one site and send two tubes.  We are hesitant to use “O’s” in these cases because it is not the best utilization.  I have looked through previous postings and don’t see a whole lot about the Operating Room.  Any suggestions?

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We draw 2 tubes, one at PST (pre surgical testing) and another on the day of surgery. If it is an urgent surgery with no PST sample on file, we would give type O until we received a CBC tube later (like in the Recovery Room or when they get back up to their nursing unit)and use that for our second type to limit using up all of our type O blood.

I don't think it's wise to ask the OR to draw a second sample, because they will then just draw 2 tubes and put one aside for later. People will come up with creative shortcuts, which will just undermine what you are trying to accomplish.

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We implemented this because of a non-fatal ABO hemolytic transfusion reaction. 

 

We had the exact same issue for patients who arrive in Surgery (both elective and urgent) and no one ordered pretransfusion compatibility testing. 

 

We also made in clear to everyone (for consistency house-wide) that the Blood Bank determines if a second venipuncture is required and that Blood Bank does not accept unsolicited blood samples.  We do not require a second venipuncture if the current blood sample types group O.

 

If Risk Management is driving this policy, they need to address the issue with the Surgery Department.

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It seems that the most adamant protestsors to safety measures are the ones who are most prone to making the very mistakes that lead to the policy changes: ER and OR!  They never have time to do things right or careful.

 

Agreed! Most OR admissions with have a pre-op sample so it isn't an issue. In an emergency situation surely it's better just to give O until a proper repeat has been obtained? These emergencies don't happen that often in the grand scheme of things...

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We call the pre-op area and make collect the sample, not the actual surgical team unless it is an emergency situation. They have learned we mean what we say and they do it.  Most of the time when the patient comes in for pre-op testing, if it too far ahead of time for the type and cross to be drawn the nurses order and draw an ABORH confirmation. If we don't need it (history already on file) we can cancel it. Then the TXG will be drawn in the pre-op area. If the sample was drawn ahead of time for the TXG the pre-op area will draw the confirmation. In the Children's Hospital the 2nd sample, whether confirmation or TXG, will actually be drawn in the OR because  they want to wait until the child is asleep before sticking them again if it is a young kid. It take education, education and more education and a willingness to get yelled at for a while. You absolutely must your Medical Director on board and willing to back you up.

You know of course, that every time you request a sample it is going to be a difficult patient  from whom they can't possibly obtain another sample.

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We have just adopted the bag lock FinalCheck system from Typenex.  Our OR protocol will be for 1 unit to be sent in the locked bag.  Someone from the OR calls us to confirm they were able to open it by checking the armband.  Subsequent units won't be sent locked. 

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We have recently had a rash of folks making it all the way to the OR with no blood bank testing (ex. a splenectomy with a 65 platelet count!!!)  We insist that 2 specimens be collected at different times.  Unfortunately, it is our phlebotomy team that has to gown up and go into the OR.  We will accept a fingerstick specimen for the confirmation typing. 

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I received a specimen from the OR yesterday (scheduled case with nothing drawn preop) that was missing a required ID number and the last name was spelled one way on one tube and a different way on the second tube. I told the runner that I would release uncrossmatched O Pos if necessary, but the specimen had to be recollected for the crossmatch. I was told that the surgeon would be coming to Blood Bank and scream at me....told her that was fine, but I wasn't going to run the risk of hurting someone because of sketchy patient ID. I still needed the specimen redrawn and O Pos was available. Didn't hear a peep out of them, got the new specimen immediately, and released a fully crossmatched unit as soon as it was ready without receiving another phone call.

 

You have to have rules for patient safety and you have to have the courage to stick with them. I agree - Surg and ER are the worst at demanding special treatment and that is the biggest risk for transfusion safety. The fact that their patients are actively bleeding makes the stress higher. For the sake of the patient, we have to hold our ground. We can provide type O until a proper specimen is drawn so nobody is going to bleed to death.  

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I received a specimen from the OR yesterday (scheduled case with nothing drawn preop) that was missing a required ID number and the last name was spelled one way on one tube and a different way on the second tube. I told the runner that I would release uncrossmatched O Pos if necessary, but the specimen had to be recollected for the crossmatch. I was told that the surgeon would be coming to Blood Bank and scream at me....told her that was fine, but I wasn't going to run the risk of hurting someone because of sketchy patient ID. I still needed the specimen redrawn and O Pos was available. Didn't hear a peep out of them, got the new specimen immediately, and released a fully crossmatched unit as soon as it was ready without receiving another phone call.

 

You have to have rules for patient safety and you have to have the courage to stick with them. I agree - Surg and ER are the worst at demanding special treatment and that is the biggest risk for transfusion safety. The fact that their patients are actively bleeding makes the stress higher. For the sake of the patient, we have to hold our ground. We can provide type O until a proper specimen is drawn so nobody is going to bleed to death.

 

Shocking, isn't it, that surgeons are still allowed to stomp their feet and scream? Since it is in my code of conduct here, I would be fired for that. Nice to know I'm not alone dealing with rude and unprofessional behavior from physicians.

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Our A & E draws a sample for typing & cross-matching on RTA patients prior to shifting them to OT or ICUs. The OT or ICU will draw a second sample & send it when they send request for issue, otherwise we will issue O group packed cells.

 

Yes Terri, we also do have to deal with rude and unprofessional, pampered surgeons.

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I've worked places where the blood bank techs got a bad name for having too much power.  We could say "NO" and our medical director would always back us up because it was the right thing.  It is one of those special things about dedicated blood bank personnel.  They know the principles of Immunohematology = and it really helps when the Med Dir has the faith in the staff to say do what the tech tells you to do.  I'll bet most of us have been screamed at, threatened, etc - it goes with the turf.  Like I tell my staff of all generalists:  Just say NO when you are demanded to break policy . . .  and then call for back up.

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