Manual Entry and 2nd tech review?

[ElinF]

We are a smaller hospital lab but we do a lot of blood banking. We currently perform manual gel with Tube ABOs for our crossmatch patients.  We have had 2 recent errors in ABO reporting that were clerical errors so something has to be improved.  We currently do not do a 2nd tech review of our manual entry results.  Does anyone have a good process flow for this?  

 

What do you do for techs that work by themselves on 2nd/3rd shift? 

 

Elin

[Dansket]

Were these ABO reporting errors, transcription errors or testing errors? Are your current test results (anti-A, anti-B, anti-D, etc.) entered into a computer, written on a paper worksheet or both? Need more information from you to be helpful.

[Karrieb61]

I'm not sure what you mean by "tube ABOs for our crossmatch patients" but: where are you reporting your results? Are you saying that the clerical errors are handwritten errors on a paper log sheet (like we have )? What exactly was the error- a wrong type written down that did not match the documented test results? Did you give out or crossmatch the wrong type blood?  Please let me/us know where the errors are occurring and then I can probably make a suggestion or two since we deal with potential clerical errors daily here in our small Blood Bank.

Secondly, on your second and third shift, is there one person for the entire lab or is there a second person who is trained in Blood Bank? We require two people on all three shifts to have Blood Bank training so that potential issues can be addressed. I am guessing that during the root cause analysis that you must be planning, a corrective action may be to require a check of all tech work during the same shift before blood products can be issued. So while we have  only one person floating in and out of the Blood Bank on second and third shift, we require two trained techs to double check at least blood types and medical record numbers before blood products go out the door.

More details if you can please!

[Auntie-D]

We have a double set on the computer so the results have to be entered twice, ideally (but not always) by different people

[AuntiS]

We have the same - manual gel and tube ABO. 

What we do here is have a second field in the LIS for an ABO check and Screen check.  The first tech performs the test and enters their results in the LIS.  The first tech then leaves all the tubes and card in the rack. The second tech checks re-reads the tubes and card and verifies the results are correct in the LIS.  The second tech must fill in the "check" field with their initials.  They don't retest - they just check.

I should note, we don't hold back any blood products until the second check has been completed.

Hope that helps! 

I'm going to follow this to see if there are any great ideas for us as well

[tbostock]

If you are entering results directly from the testing media (shaking a test tube, reading a gel card) into the computer a second check should not be necessary.  Blood Bank systems are usually set up with a "verification" step where the technologist has a chance to review the results on screen before accepting the results.  If errors like this are happening, this is probably tech error (carelessness) that needs addressing with corrective action.

 

If you are transcribing results (copying your results that are handwritten or computer generated on a piece of paper into a computer system), there is a much greater chance of clerical error.  Anytime this is done, you should have another BB qualified tech immediately review the accuracy of the manually entered results and cosign (or initial) the paper and keep this documentation for review by inspectors.  The supervisor then reviews that this is being consistently done.

 

If a clerical error is due to two patient's results being "mixed up" by the tech when entering, you need to look at your policies/procedures concerning multiple samples.  We only allow one patient's blood types to be centrifuged/documented at a time and the test tubes discarded before starting the next patient's blood types.

[Auntie-D]

Tbostock - I disagree. Any time anybody does anything manually it should be checked. Transcription errors can occur between testing media also.

[Dansket]

A small facility doing a lot of blood banking by generalists should seriously consider an automated testing platform.  Automated testing eliminates a wide range of errors associated with specimen identification, test tube labeling/handling, results entry, results interpretation and transcription. 

 

Our platform prints a report with results and results interpretation.  We affix a barcoded sample label to the report (one patient per sheet of paper).  The barcode on the report is scanned into the LIS result entry routine and results are transcribed.  This system works 24/7/365 with a single individual wholly responsible for results entry.  I have used this system successfully over the past 10 years, both in a 525 bed Level II trauma center (>10000 rbcs transfused annually) and a 100 bed (<50% occupancy) community hospital(<1100 rbcs transfused annually).

 

I believe that any strategy that relies on double-checking a process by multiple individuals will fail.  If an individual cannot accurately transcribe results in the system described above, they should not be working in a transfusion service.

 

Blood bankers need to embrace automation in the 21st century and discard 20th century manual processes.

 

Whew!!,  I feel so much better now.  Thanks.

[AMcCord]

I require a second check of all documentation prior to issue of blood products - patient report and unit tags against order and results. The double check was instituted because of some clerical errors, not technical errors. The double check is documented on the product tag and on the patient report. We do automated testing, but our documentation is all paper (insane, I know  ). We have 2 techs on the night shift. One crew has one tech with limited function in blood bank, so I specifically trained to her to verify documentation (and test her periodically to make sure that she's doing it diligently). Our error rate on final reports has dropped dramatically.

[mollyredone]

I agree with Terri.  Our techs work alone in BB and only work with one type at a time.  Results are put in the computer immediately.  The computer system has a verification if the reactions that are entered do not match the type entered by the tech.  We require a "type check" for a patient without a previous type.

[cthherbal ☆]

Need more information to accurately comment. I have some questions- Do you put results in a LIS or on paper? If LIS, is the LIS a blood bank system or do you just put type and screen interpretations in? Does the LIS QA check previous results- for example, if someone was previously entered as O pos and on this admission is A pos, will there be a hard stop/warning? If only on paper, have a second tech review the work and perform a 2nd blood type on another sample before any crossmatching takes place. This is critical to prevent mis-transfusions.

[tbostock]

Tbostock - I disagree. Any time anybody does anything manually it should be checked. Transcription errors can occur between testing media also.

 

Ideally, yes, but this would require two Blood Bank techs sitting side by side at all times working on each sample together. 

Any type of retrospective manual checks of tube or gel testing results where the actual testing media (test tubes, gel cards, etc) have already been discarded or are hours old does not have the same value as solidly built computer checks and careful resulting by the techs.  Supervisor review of results is necessary, of course.

[COTTONBALL]

Please provide additional information.

[seraph44]

We also use manual gel (assuming you're talking about the screen) and tube ABO, No second tech, and require a second sample to give type specific. Our LIS will catch any clerical input and prompt before verifying results. Most LIS are built like that, so I'm guessing the LIS you have might be a DOS based system or completely manual system that does not include that type of logic or they are being transcribed in the system incorrectly. Either problem, in my opinion, is solved with proper training. Sometimes people do not have the BB background and are put into working BB independently too soon. When dealing with multiple patients, I like to alphabetize them in my rack, my centrifuge, and my LIS. This helps with the mixing up of patients.

[tbostock]

 When dealing with multiple patients, I like to alphabetize them in my rack, my centrifuge, and my LIS. This helps with the mixing up of patients.

 

LOL, I thought I was the only one that went this far.  I have always alphabetized them and still recommend that to trainees and they look at me like I'm crazy.

[aafrin]

We also use tube testing for Blood Grouping and MAnual gel for crossmatching. We do a lot of blood groups daily and all the groups are read by two techs independently who sign in the register. The same tubes are then reviewed by me or MO for the blood bank and we also sign in the register.To avoid mix-ups when dealing with multiple patients, we number each patient sample tube with the serial number it is entered in the register, and all the 8 small tubes are also marked with the same number. Tubes without number are not read. Numbering each tube is a lot of work, but it gives peace of mind. Also if there is shortage of techs in aparticular shift or on holidays the rack can be stored and read later.

But as Dansket said earlier we are waitng for automation to take us to 21st century procedures....hope that day will dawn soon.

[Likewine99]

I too alphabetize my pts, either in a rack or on the Provue.  Unless it's a stat then that goes first.  If there is more than one stat I alphabetize those.  

 

I too was trained this way, back in the day, way back in the day.

[AMcCord]

Not only do I alphabetize my patients, I put my donors in numerical order by the last 2 or 3 digits. How's that for anal?

[Auntie-D]

Not only do I alphabetize my patients, I put my donors in numerical order by the last 2 or 3 digits. How's that for anal?

 

I do that too...

[tbostock]

OCD support group going on right here.

[Auntie-D]

OCD support group going on right here.

 

OCD saves jjobs and lives

[CMCDCHI]

Adding additional tech checks isn't always the answer.  There is a lot of confirmation bias in performing 2nd checks.

[Auntie-D]

Adding additional tech checks isn't always the answer.  There is a lot of confirmation bias in performing 2nd checks.

 

How? Most SHOT/SABRE reports are from errors found by checks, not from ones where something has gone wrong because someone though someone else would find the error. I'm actually quite insulted that anyone would think as a professional that anyone would do this. And if you do have staff like this in your lab then it is an inherant flaw in the culture in the lab that needs looking at, not the process itself, and that reflects really badly on the laboratory.

 

I've found there are 3 groups of people - those with a conscience who take extra care because they would hate for someone to find their mistake, those who couldn't care less and the third type, who keep the second type in check - those who take delight in finding an error thast somoene else has missed. Very few people are that unporfessional that they would check less carefully becuase they know that someone else would find it - I for one would be devestated!

 

I know of at least 2 occasions where a second check has picked up a discrepancy. Once a wrong patient discrepancy and once a missed weak-D

Edited December 31, 2014 by Auntie-D

[L106]

I too alphabetize my pts, either in a rack or on the Provue.  Unless it's a stat then that goes first.  If there is more than one stat I alphabetize those.  

 

I too was trained this way, back in the day, way back in the day.

 

I do the same.

[CMCDCHI]

Auntie-D, I certainly didn't set out to insult anyone.  I was simply commenting from my experiences and those I have heard from others.  The tone of your response was certainly accusatory.  One of the things I appreciate most about this site is the openess of the members and I hope it stays that way to encourage conversation.

 

Confirmation bias does not mean that someone was intentionally careless, it is often subconsious.  There is also plenty of use for 2nd checks (we use several), but it should not always be the answer without an investigation of the process.  Unnecessary checks can bog down a process, add cost and time, and sometimes not even add to the safety/accuracy of the process.