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Second ABO/Rh sample


cheru26

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Just a reminder, two draws does NOT guarentee that there will be no wrong-blood-in-tube.  If the patient is misidentified once, it can happen again. 

 

Agree with pbaker, above.  No system is going to be foolproof.  100% reliance on policies to protect patients is not going to protect patients in all situations.

 

Scott

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We give all of our neonates group O blood so I wouldn't worry about getting a second type on them since we can't give the wrong blood group if the first type was wrong.

Ditto.

Perhaps the logical solution to the problem of 'not wanting to redraw a neonate' is to restrict neonates to Group O.  That follows the policy actually ... 'Give Group O until a second sample  ... blah, blah, blah.'

 

Love the 'Bombay' comment, btw ... 

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Generally we do not draw a second sample.

     Since the purpose is to be sure there was no error - WBIT, we have 2 phlebotomists (nurses or lab) identify the patient by AABB standards (pg 368, 18th ed. Technical Manual).     

     Unequivocal ID of the patient shall be made before drawing blood specimens. If any errors or discrepancies are found during this process of ID, blood specimens shall not be drawn until resolved.

     BLOOD SPECIMENS MUST BE LABELLED AND SIGNED IN THE PRESENCE OF THE PATIENT. Minimum requirement as stated by AABB: “2 independent patient identifiers and date collection”. Patient’s last and first names, unique ID number (visit ID, MR#, DOB, BB#), date and phlebotomist’s signature, as well as the signature of the 2nd verifying person. The 2nd person signing must be present in the room when blood is being drawn. If 2nd signer was not in the room when phlebotomist verified the patient’s information, (s)he must confirm the patient’s ID again. Patients may not be banded after blood has been taken out of patient’s presence. If the phlebotomist leaves the room prior to tube being signed, the specimen must be re-drawn. If two signatures and/or hospital IDs are not on the tube, a second specimen drawn at a different time (must be properly labeled).          

     All patients must be banded with either a hospital ID band or the Red Blood Bank band (drawing of an out-patient). This band must remain on the patient from the time of specimen collection until the transfusion episode is complete. 

     Since only Blood Bank tubes are signed this way, we would not use a hematology tube. The OB nurses identify,sign, and label the cord specimen  in this manner as well.

     FYI, the only floor we really have to reject specimens from now and then for not following the "RULES" - you guessed it- the ER.

We also use BB Bands so we do not require a second specimen.  We do require a second tech perform a recheck if there are no previous BB Banded specimen ABO/Rh on record. (Prenatal, hearsay, etc. doesn't count.).

And ditto: No BB Band = No Transfusion.  (Take it 'Uncrossmatched' until a valid specimen is drawn and all required testing is done.)

 

Just because 2 specimens are the same blood type doesn't mean they came from the same patient.  You still don't know if the first one was right ... or the second one.

 

Well, that's what we tell Hemo when they come in asking us to type two specimens bearing the same name that fail delta check ... why do people think it is any different for Blood Bank?

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To original question; in our lab neonatal blood group typing is valid until 6 months of ages. If baby needs blood products another sample must be drawn. From the second sample we do ABO, antibody screening (four cells) and IAT with A1- and B-cells to make sure there is no immunisation. For very small

babys and babys requiring intensive care unit, (electronic) cross-match is valid for 16 weeks. For others it is five days.

 

We give ABO RhD typed matching blood for babies, we do not give babies only O blood. Plasma products are AB. If the mother has any blood group antibodies we take them into account and give blood that could fit the mother (other phenotypes, not the ABO)  also.

 

We tend not to use hematology tubes because tubes for blood bank are always signed. But occasionally (mostly with children) we can search for the hematology tube.

 

Interesting conversation!

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Sorry.  It certainly does Mabel; just like anti-A and anti-B.

 

It is highly unlikely, therefore, that an anti-H would be strong enough in a neonate to cause a transfusion reaction as, 1) the anti-H would have to be maternal (which means that the mother would also have to be an Oh, and the father would have to be hh or Hh too), and 2) the neonate would have to require a transfusion for a reason other than HDFN.

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Sorry.  It certainly does Mabel; just like anti-A and anti-B.

 

It is highly unlikely, therefore, that an anti-H would be strong enough in a neonate to cause a transfusion reaction as, 1) the anti-H would have to be maternal (which means that the mother would also have to be an Oh, and the father would have to be hh or Hh too), and 2) the neonate would have to require a transfusion for a reason other than HDFN.

I always thought anti-H was IgM and therefore not capable of causing HDFN.   I am not aware of any cases of HDFN due to anti-H.

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No, anti-H is like anti-A and anti-B (and anti-A,B, come to that) in that it is mostly IgM, but there can often be quite an element of IgG there too.

 

There is a case described by Moores et al that was severe (Moores PP, Smart E, Gabriel B.  Hemolytic disease of the newborn in infants of an Oh mother.  Transfusion 1994; 34: 1015-1016).

 

Whilst it may be argued that this is an unusual, if not unique report of anti-H causing HDFN, the rarity of IgG anti-H in an Oh mother, together with the relative rarity of clinically significant HDFN caused by the more common anti-A, anti-B and anti-A,B, it is not a surprise that this condition is very rare, but is neither unknown, nor impossible.

 

It should never be dismissed out of hand.

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  • 3 months later...

Whether or not,  a second blood sample is required is driven solely by the actions of the CLS doing the initial ABO/Rh determination on a current blood sample.  It is not a Nursing decision, not an MD decision and not a phlebotomist decision.  We do not accept unsolicited blood samples collected by anyone, including anesthesiologists in Surgery, other medical personnel in ER or Trauma, to be used for ABO confirmatory testing.

 

If there is no "ABO,Rh" on file in the computer system, the current uncentrifuged blood sample is tested with anti-A,B (tube test).  Results of the anti-A,B test are entered in Meditech 5.66 and filed.  If anti-A,B test was positive, Meditech automatically reflexes an ABO confirmatory test using a new specimen number and prints specimen collection labels on the Phlebotomy label printer. 

 

We use the TYPENEX Blood-Recipient Identification system and require that labeling of the confirmatory blood sample include the TYPENEX number/letter code (only available at patient bedside).  This code must be entered in Meditech with the confirmatory test results.  Meditech is configured so that confirmatory results cannot be filed/verified if the TYPENEX code does not match the TYPENEX code previously entered on the current blood sample. 

 

ABO/Rh determination and ABO confirmatory testing are done on ProVue and results entered in Meditech.  Meditech is configured so that ABO determination cannot be calculated if the anti-A,B test result does not agree with ABO determination test results.  Meditech is also configured so that blood components cannot be issued if the ABO confirmatory test on the second blood sample has not been done or does not agree with the ABO determination done on the first blood sample.

 

Collection of the second blood sample is rigorously controlled to insure that a venipuncture is done after a second visit to the patient's bedside.

Edited by Dansket
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My hospital is using what they call  Mobile Care Phlebotomy.   The patient is given an armband at admissions with a bar code.   Once they have orders that barcoded label on the patient is scanned and labels are printed on a handheld printer.  They label at bedside and we have gotten rid of the second sample ABO/retype.  On the first visit the patient is required to have an IS XM. After that they have an Electronic XM.  It's been going great.

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My hospital is using what they call  Mobile Care Phlebotomy.   The patient is given an armband at admissions with a bar code.   Once they have orders that barcoded label on the patient is scanned and labels are printed on a handheld printer.  They label at bedside and we have gotten rid of the second sample ABO/retype.  On the first visit the patient is required to have an IS XM. After that they have an Electronic XM.  It's been going great.

 

Going great until one day someone prelabels a tube and bleeds a different patient...

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Or the wrong armband is put on the patient in the first place. If the patient is not IDed by asking them their name and birthdate, or if a nurse who knows that patient doesn't ID them when they can't ID themselves, you can still get WBIT.

 

We do use the mobile devices and have had some mislabeled specimens - thankfully not blood bank. The phleb IDed the patient verbally, scanned the patient's armband and printed the labels at bedside for the tests to be drawn - so far so good and following policy. She then failed to get a sample from the patient and left to draw the next patient. What she did not do was tear off and discard the labels she'd printed after IDing the previous patient, so the next patient's samples got labeled with those. She managed to do it twice in one week. She's now working in another department of our facility - not because of the labeling errors, but because she felt that phleb was not a good fit for her (Ya think?!!). After that a 'final check' policy was put in place. Before the phleb leaves the bedside, the tube labels are supposed to be compared to the patient's armband. Still not foolproof if the step is ignored or done casually.

 

Could we still have a labeling error - absolutely! The whole house of cards is totally dependent upon everyone following policy. If one person decides one of those steps is silly or they 'don't have time', then the cards come tumbling down and we have WBIT. The Swiss cheese principle also applies. Do I think the mobile devices are an improvement? Yes, they are. We definitely have fewer issues, but we police the heck out of the process. Someone follows every phleb to the floor twice a month and watches their process for drawing blood bank samples. Keeps them from developing their own shortcuts or inadvertently changing the process. Doesn't mean that someone won't freelance when we're not watching them. Bottom line...you cannot blindly trust that device alone.

 

Nurses give meds scanning those armbands, except that sometimes they find it a bit tricky to get the barcode to read. Guess what they do? They put a chart sticker with that barcode on a paper towel, a piece of scrap paper or the back of their hand and scan that. They get reported when anyone from lab spots it, but how often is it not spotted and/or reported? People can always circumnavigate your process.

 

They want to give blood without a second person checking patient ID and using only an armband scan for patient ID. Gives me the shivers just thinking about it! (And since we don't have a blood bank computer system, it's a non-issue right now.) We do use the Final Check blood lock system as an additional part of the safety process and I suspect that we will continue to do so if and when we issue blood that will be matched to the patient by a bar code scan. (And we police the proper use of the lock as well. Strong disciplinary action would be applied to offenders.)

 

Whew! where did all that come from :crazy::confuse: ?  As they say in the arms control business...'Trust, but verify.' :peaceman:

Edited by AMcCord
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Since we staff with so many part time techs, we require a second sample on neonates to keep the policy consistent. We don't get transfer babies so we would have the cord or a previous hematology specimen. On adults without a second type we give O Rh specific. However, we routinely do electronic crossmatches & we have to do an immediate spin crossmatch without a second type. The computer requires overrides, even with group O units.

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On infants/newborns  that would have to NOT be a cord blood type.  then the type should be good for 4 months.  The hospital can set stricter requirements than the standards.  For older children (<5) I would think a finger stick could accomplish a second type with only one or 2 drops of blood - you'd only need a front type as a confirmatory type UNLESS your policy states you need two complete types . . .

To ensure compliance with AABB Standard 5.16.2.2 if you use an electronic crossmatch you need to perform both front and back types (AABB 5.14.1).

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For any non-transfusion ABO/Rh specimens, does anyone add a statement to the test result indicating there was no historic type of file or testing was performed on a single specimen?  We are considering doing this for our outpatient ABO/Rh typing for prenatal patients.  If so, what language do you include in the statement?

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For any non-transfusion ABO/Rh specimens, does anyone add a statement to the test result indicating there was no historic type of file or testing was performed on a single specimen?  We are considering doing this for our outpatient ABO/Rh typing for prenatal patients.  If so, what language do you include in the statement?

 

In my previous lab we used to put the antibody flag 'UNEI' - Unsuitable for electronic issue (we didn't term it electronic crossmatch as an electronic crossmatch for us was one that had been crossmatched on the analyser) for patients where only one sample had been received (or the analyser result had been manually edited). Once a second (or unadulterated) sample had been received this antibody flag was removed.

Edited by Auntie-D
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This isn't a regulatory requirement unless you do not maintain your BB history to compare records for the last 12 months, which we all do. 

 

We receive a lot of specimens from physicians offices, etc.  As with any test, our results are only as good as the initial patient verification/labeling.  Even though we are comparing records to our historic data, many of these patient's are new to us.  We were considering some type of statement to indicate we did not have another sample to compare the results to or no previous ABO/Rh history record on file.  I remembered seeing that someone was adding a similar statement, but I could not remember where I read it.  

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We comment in our worklog things like " no history" or "type on file, no historic antibody" or "type on file, no antibody history". If we were doing electronic crossmatch (no computer...sigh) I would change that policy to possibly indicate that the specimen was not collected by us with a statement in the SOP that such specimens do not meed requirements for typing for electronic issue. I like the idea of the antibody flag which is removed when 2 in house types are done.

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We also put a computer flag to indicate a second ABO has been done in-house.  We require this even for patients who do not qualify for electronic crossmatch.  Blood cannot be issued through the computer unless the patient is flagged accordingly.  However, this is not part of any patient report.

 

It would be interesting to know if large reference labs like LabCorp or Quest routinely incorporate such a waiver on every non-transfusion ABO/Rh determination they report, regardless of who collected the blood sample.

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For any non-transfusion ABO/Rh specimens, does anyone add a statement to the test result indicating there was no historic type of file or testing was performed on a single specimen?  We are considering doing this for our outpatient ABO/Rh typing for prenatal patients.  If so, what language do you include in the statement?

 

 

Have never done this.  Not aware of any such requirement by regulatory agencies.  Can you reveal the circumstances that lead to this discussion?

 

In CAP Transfusion Medicine Checklist, under Perinatal Testing:

 

TRM.40820 Historical Record Check Phase II

There is a written procedure to ensure that laboratory records for ABO/Rh testing are

searched for each pregnant patient for at least the preceding 12 months.

NOTE: The purpose of this comparison is to detect sample/patient identification errors or other

errors that might lead to the attribution of an incorrect blood type or antibody screen result to

a pregnant patient; this might result in a missed opportunity to provide prophylaxis against or

appropriate treatment for perinatal alloimmunization. If the laboratory performing the testing does

not maintain records that would allow this check to be performed, the testing shall be reported

with a disclaimer alerting the ordering physician that the check has not been performed and that

verifications of the sample's identity and the test results are strongly recommended.

Evidence of Compliance:

✓ Written procedure for checking ABO/Rh and antibody screening results with historical results

AND

✓ Records of historical checks

Edited by goodchild
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In CAP Transfusion Medicine Checklist, under Perinatal Testing:

 

TRM.40820 Historical Record Check Phase II

There is a written procedure to ensure that laboratory records for ABO/Rh testing are

searched for each pregnant patient for at least the preceding 12 months.

NOTE: The purpose of this comparison is to detect sample/patient identification errors or other

errors that might lead to the attribution of an incorrect blood type or antibody screen result to

a pregnant patient; this might result in a missed opportunity to provide prophylaxis against or

appropriate treatment for perinatal alloimmunization. If the laboratory performing the testing does

not maintain records that would allow this check to be performed, the testing shall be reported

with a disclaimer alerting the ordering physician that the check has not been performed and that

verifications of the sample's identity and the test results are strongly recommended.

Evidence of Compliance:

✓ Written procedure for checking ABO/Rh and antibody screening results with historical results

AND

✓ Records of historical checks

Thanks, goodchild,

 

I'd taken this CAP requirement for granted as I have been using computer systems that automatically met this requirement over past 20+ years.  As a result, I have never been cited for not doing this check or for not reporting ABO/Rh testing with a disclaimer when there was no historical record on a pregnant patient.

 

I interpret CAP's note  to TRM.40820 as requiring a disclaimer only if a historical records check was not done.  I would need to see much stronger or more explicit language from CAP to compel me to routinely report a disclaimer when there was no historical record on a pregnant patient in the preceding 12 months.

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"I interpret CAP's note  to TRM.40820 as requiring a disclaimer only if a historical records check was not done.  I would need to see much stronger or more explicit language from CAP to compel me to routinely report a disclaimer when there was no historical record on a pregnant patient in the preceding 12 months."

 

I agree with Dan's statement. We do not have a computer and never have, so our checks are manual. We check our patient history file for every specimen/order we receive and I have a policy that requires that we do so. We maintain patient records for the time required by standards, also stated in policy (in practice, we actually have records much longer than required and will until the file cabinet burps). We document the history check of those records, as required by policy. The worksheet has a column for a check mark, which indicates that we have evaluated the specimen/order for acceptability and checked the history file. We also add an appropriate comment to each patient entry: "No history"; "Type on file/no hist ab"; "Type on file/no prev ab scrn"; etc. These comments are for internal use only and do not appear on patient reports.

 

If you do not keep records, there's nothing to check - no way to catch errors. I feel that's the situation that would require a disclaimer. I wonder if the requirement for the disclaimer is aimed at reference labs or clinic labs? What hospital lab doesn't have records to check?

 

I believe that checking our records for patient history, documenting that check and having a policy or policies to require both meets the intent of the standard. I've passed 8 or 9 CAP inspections, including one a month ago, and 2 CLIA inspections in the last 4 years doing what I've described. There have been no concerns about this in any of those inspections.

 

Doesn't mean they won't change the standard next month - I'll cross that bridge when I have to.

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I actually have this on my list of things to discuss with CAP because it's somewhat ambiguous. The way I read it leads me to believe if you don't have a previous record (and no second specimen drawn to confirm type) then a disclaimer should be released with the result.

 

Performing a check but having no previous record to check doesn't seem like it exempts you from the purpose they describe in the note: "to detect sample/patient identification errors ...; this might lead to a missed opportunity to provide prophylaxis against or appropriate treatment for perinatal alloimmunization."

 

Seems like this is aimed at places that do outpatient/clinic prenatal testing.

 

Granted, I haven't implemented anything like this at my institution (yet?).

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