blood boxes delivered straight to O. R. & they want to give it!

[Mabel Adams]

Does anyone have any true stories (de-identified of course) of a bad outcome because someone took an incoming shipment of blood straight to the O. R. (and they transfused it or nearly did) instead of taking it to the lab to be properly logged in, crossmatched and issued to the patient (or even identified as uncrossmatched universal donor blood)?  Our O. R. leadership doesn't think it is a big deal.  I'd appreciate any information that I might use to convince them otherwise that they won't just see as blood banker hysteria.

[Teristella]

That is quite possibly the most terrifying idea I have heard of a department thinking is an alright thing to do!

I do not have any stories to share (thankfully?!) but I feel like there are numerous regulations you could cite, CAP and otherwise. Joint Commission would probably have a cow as well.

Edited August 26, 2016 by Teristella

[Gkloc]

I agree with Teristella, and thankfully I have no stories like this to share. Here is an AABB standard that you can use:

4.3 Incoming Receipt, Inspection, and Testing

     Incoming blood, blood components, tissue, derivatives, and critical materials shall be received, inspected and tested, as          necessary, before acceptance or use.

[AMcCord]

I would say that it is also a CBER reportable event, potentially in multiple categories:

QC-96-02 or -04 Product arrived at unacceptable temperature or no documentation that product was shipped and stored at appropriate temperature. (Was any inspection done/documented to prove the units were OK? would surgery even know what was OK?)

QC-96-07 Product not packed in accordance with specifications or no documentation that product was packed appropriately. (would surgery know what was appropriate packing? would they keep the packing slip and give it to blood bank?)

QC-97-13 Procedure for issuing not performed or documented. (I'm sure you don't have a procedure that says incoming units go straight to the OR for issue with nothing done prior to sending them to the OR.)

QC-97-14 ABO and/or Rh retype of unit not performed.

QC-97-15 Visual inspection not performed, not documented or inadequate (would surgery even know what they were looking for or know that they needed to do that? or document it if they did inspect the units - its a bear getting them to document what units were actually given when they are dealing with a mass transfusion event much less other 'silly stuff' they don't see the point of doing)

QC-97-19 If not issued in computer - includes emergency release.

I'm sure I've missed something.

If this was reported more than as a one time event, I would wonder if that would pique someone's interest enough to send an inspector?

I would think that the facility quality department and risk management would be having a cow along with Joint Commission.

Double Yikes!!

As to  stories - how about the young girl that got a heart transplant of the wrong type because nobody bothered to check the blood type, just assumed everything was A-OK. She died. That's not blood, but the same process/error would apply to the assumption that a box full of blood is always going to be the right type for the patient in question. Blood centers are staffed by humans who can make mistakes. I'll bet everyone who's worked in blood bank for more than a few years has unpacked a shipment of blood at some point in their career that had units that were not the type you ordered. I have. Dump those straight into a patient without questioning? - recipe for disaster!

Edited August 26, 2016 by AMcCord

[David Saikin]

debatable whether it is a BPD.  you never had control of the product.

I worked at a large University Hospital.  If we sent out for blood for an OR case sometimes the blood would be delivered to the OR because they "knew" it was for that case.  I had xm'd units in the OR ref for the patient and caught the residents taking blood out of the transport box instead . . . You have to remember, there is minimal training to most MDs regarding blood.  Only how to use it, not the finer points.  Sometimes, a lot of times, you even have to chide the pathology residents . . . They told let the docs be stupid, don't let them kill anyone.

[Teristella]

Yes, I think getting your facility's quality/risk management department involved might be a good idea. The idea of sending a report to the FDA might prompt them to get involved.

[AMcCord]

8 minutes ago, David Saikin said:

debatable whether it is a BPD.  you never had control of the product.

 

You may have a point there - however, the folks in surgery wouldn't know that. Might still make a good stick to threaten them with .

As David says, you do have to be ready to save the patient from their caregiver if necessary.

[Mabel Adams]

Thanks for some great ideas.  I'm still interested in more.  This is not the last time this will come up, I am sure.

[Teristella]

Who took the shipment to the OR anyway? The blood supplier? Or do they drop it off with someone in the facility? If your supplier's couriers are taking products straight to the OR, you would probably want to address that with the supplier to prevent it from happening in the first place.

[Mabel Adams]

This case was a shipment between our hospitals.  Of course the courier was new and the receiving hospital was on lockdown so he may have had to take a different path to the lab.  We are definitely working on the courier end but they have a fairly high turnover so it could happen again.  We are thinking of giving every new courier "ten commandments of transporting blood products" to keep in their pocket or some such.

We had a similar situation a few months ago when the state police brought a shipment from our supplier and dropped it off at our ED.  In the few minutes before I could intercept it, the blood boxes were already taken to the OR.  At least in that case O. R. was contacting us to come get it just as I got there.

[David Saikin]

9 hours ago, Teristella said:

Yes, I think getting your facility's quality/risk management department involved might be a good idea. The idea of sending a report to the FDA might prompt them to get involved.

That happened decades ago - in a galaxy far, far away.  We had University security who would make the run for blood.  They were supposed to bring it to the BB but sometimes they were "confused".