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Emergency Release Labeling


EAB81

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This may be a no brainer, but I'm just gonna put the feelers out there :)

Our risk management came to me a week ago and inquired about the specific labeling we use for emergency release units. She happens to be the risk manager for 2 facilities, including mine, and there was an issue at the sister facility regarding labeling. Apparently, there was no time to get an armbanded sample in surgery, and the patient had no previous history. So, the BB sent out a unit of AB FFP but did not put any labels on the product indicating whom it was for. The nurses were baffled and didn't know what to do about it. Well, this has sparked conversation regarding labeling of any emergency released products.

 If we are giving universally compatible blood or products in an emergent situation, do we need to put labels on it indicating to which patient it goes to as long as we have an Emergency Release form that the physician will sign indicating who and what unit?  I ask this because the majority of our ER occurs in the emergency room where we might not know what the patient's name is right away but can't keep them from transfusing the blood til we get that info. Would you just label it as Jane Doe or John Doe?  I personally, have always just filled out the ER form, had the physician sign it, and use bright colored stickers that say "UNCROSSMATCHED BLOOD." There's not been any issue til now.

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We were cited last year for not labeling emergency release products.  It was deemed an unsafe practice.  Now we ask for the patients names and medical record number.  If they don't have one, a temporary one is to be assigned and that info is provided to us.  We then need to use a different system to print these stickers to place on the emergency release tags that we attach to the units.  This can take a fair amount of time, but somehow is felt to be safer.  Very frustrating.

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10 minutes ago, Cliff said:

We were cited last year for not labeling emergency release products.  It was deemed an unsafe practice.  Now we ask for the patients names and medical record number.  If they don't have one, a temporary one is to be assigned and that info is provided to us.  We then need to use a different system to print these stickers to place on the emergency release tags that we attach to the units.  This can take a fair amount of time, but somehow is felt to be safer.  Very frustrating.

Currently, our blood bank system does not allow us to have labels printed as we dispense units. So, everything has to be handwritten. We will be getting Cerner sometime in late 2018, and that will change, but we have to do something before then. Another facility just has labels printed up that they write the info on and place on the unit along with another brightly colored sticker that says "Uncrossmatched." I'm not sure if that's the route we wanna go here. I'm definitely open to suggestions.

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As I mentioned, we need to go to a separate system just to print the labels to stick on to generic emergency release forms.  All of this adds time.  We are a large level 1 trauma center with a very active labor center.  We have many emergency release situations.  Some with dozens of products.  This adds no safety at all and adds time; therefore in my humble opinion, decreases patient safety.

If I give an o neg RBC to the wrong patient (both of whom were going to get emergency released products), did I harm anyone?

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9 hours ago, Cliff said:

As I mentioned, we need to go to a separate system just to print the labels to stick on to generic emergency release forms.  All of this adds time.  We are a large level 1 trauma center with a very active labor center.  We have many emergency release situations.  Some with dozens of products.  This adds no safety at all and adds time; therefore in my humble opinion, decreases patient safety.

If I give an o neg RBC to the wrong patient (both of whom were going to get emergency released products), did I harm anyone?

I agree entirely Cliff, but, in the UK, largely as a result of The Blood Safety and Quality Regulations (BSQR), originally introduced in 2005 by the European Union (EU), we have to have an audit trail from vein to vein for all units of blood, blood components and blood products, and this is seen by the inspectors as MUCH more important than the mere life of a patient.  Woe betide anyone who does not have a full audit trail and proof of cold chain, as they will have their finger nails ripped out without anaesthetic, then chucked into jail and the cell key thrown away.  In other words, while I agree that there should be audit trails and cold chain proof, the attitude is totally over the top.

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I'm stretching the old memory cells here but I'm going to try.  We had a number of arm bands pre-made for trauma and disaster patients as well as a few of OB bleeding emergencies.  These arm bands resided in the Emergency Room and L&D to be used for identification purposes when needed.  In this manner we were able to maintain our normal routine with very minor modifications. These arm bands stayed attached to the patient through out their hospital stay.  When the dust cleared all records for these patients contained both their emergency ID as well as their "real" one.  This system seemed to work very well the times we needed it.  It was practiced a couple of times each year with disaster drills to keep everyone involved current on the procedures.

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7 hours ago, Malcolm Needs said:

I agree entirely Cliff, but, in the UK, largely as a result of The Blood Safety and Quality Regulations (BSQR), originally introduced in 2005 by the European Union (EU), we have to have an audit trail from vein to vein for all units of blood, blood components and blood products, and this is seen by the inspectors as MUCH more important than the mere life of a patient.  Woe betide anyone who does not have a full audit trail and proof of cold chain, as they will have their finger nails ripped out without anaesthetic, then chucked into jail and the cell key thrown away.  In other words, while I agree that there should be audit trails and cold chain proof, the attitude is totally over the top.

Yup, that was about how our inspection went.  We were made to feel like we were murdering patients by not having a fake name, attached to a universally "safe" product, being infused into a exsanguinating, unidentified patient.

I understand the need for rules, but saving the patient comes first.  We do have a trail of who got what.  The idea that having a fake name on a product makes is safer is very frustrating. 

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Over the years I came to realize that a lot of what we did was geared toward simply passing inspections and meeting requirement that, in reality, did little or nothing to aid the patients.  Smoke and mirrors to confound the masses. 

I've said this multiple time on this site and still believe it strongly; "Complicating a process never made it better!" yet every time something happened everyone's first response was to add more layers to the process in a effort to make it fool proof until some new fool came along. 

Human error will occur as long as humans are involved.  All we can hope for is minimizing the impact.  This statement used to make our corporate transfusion QA folks lose their minds.  

I've kinda taken a tangent for a moment.  Getting back on track, Cliff and Malcolm I agree with you completely.

:coffeecup:

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21 minutes ago, John C. Staley said:

Over the years I came to realize that a lot of what we did was geared toward simply passing inspections and meeting requirement that, in reality, did little or nothing to aid the patients.  Smoke and mirrors to confound the masses. 

Agreed. It is very easy to fall down the "What if?" rabbit hole and get lost in the details. Complicated systems lend themselves to failures and unofficial shortcuts.

The various regulatory agencies were supposed to be incorporating a risk-based approach to their inspections. One could argue that it worked for a while, but now in the absence of big issues, the inspectors are back to the minutiae.

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On ‎11‎/‎26‎/‎2017 at 7:37 AM, John C. Staley said:

We had a number of arm bands pre-made for trauma and disaster patients as well as a few of OB bleeding emergencies.  These arm bands resided in the Emergency Room and L&D to be used for identification purposes when needed.  In this manner we were able to maintain our normal routine with very minor modifications. These arm bands stayed attached to the patient through out their hospital stay.  When the dust cleared all records for these patients contained both their emergency ID as well as their "real" one.

This is roughly what our current procedure is too.  We call them Rapid ID packs, but they are only in our ER.  I wonder if L&D would ever need them here?  Have to check into that....

Just to hijack this thread farther  - does anyone have an extensive Disaster Plan that covers both internal disasters, external disasters and  (God help us all) Mass casualty events??  I have been trying to write something for quite a while - but everything seems to be just too little or too much.  What do you put down on paper and does it ever help anyway?  What do you practice/drill?

We have 2 100 bed hospitals, two E.R.s (about 20 beds each), 2 college campuses, 4 High schools and a few dozens mid and elementary facilities.  Our blood center is about 1 hour away.  

Can anyone share what they may have?  Can anyone from Las Vegas, NV, USA share anything??  Can't imagine what your night was like at all....

Carolyn.swickard@lpnt.net

Thanks for any help.

 

Edited by carolyn swickard
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On 11/25/2017 at 6:25 PM, Cliff said:

As I mentioned, we need to go to a separate system just to print the labels to stick on to generic emergency release forms.  All of this adds time.  We are a large level 1 trauma center with a very active labor center.  We have many emergency release situations.  Some with dozens of products.  This adds no safety at all and adds time; therefore in my humble opinion, decreases patient safety.

If I give an o neg RBC to the wrong patient (both of whom were going to get emergency released products), did I harm anyone?

I do not see anyone here defending the idea that you need to know, with absolute certainty, where each human blood product goes and who ends up with the transfusion.  Every transfusion is a transplant.  Do we really need to review why we cannot issue products willy-nilly no matter how 'universal donor' they are?

There are several suggestions here already for policies to ID John/Jane Does and the units they receive.  It takes consultation and cooperation between multiple departments; and yes, its going to take some work.  Once implemented, an appropriate system will satisfy regulators without any loss to patient care. (Blaming regulations that may be "inconvenient" when pointing out our deficiencies does little to help our patients.)

Scott

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@SMILLER, we have always been able to determine who received our products, including all emergency release products.  We have a form the physician signs that lists the units.  The blood bank issues those products (when they have time) to that patient and we can track where every product goes.

What I take exception to is the inspector insisting that we also put the patients name and MRN on the product.  They again insisted this made the process safer.  It does not in any way make it safer, especially if it's a system assigned name / MRN and more importantly, when it takes a modest amount of time to generate these labels.

We have done a tremendous amount of planning to ensure we can give out emergency release coolers, almost on demand.  It takes us very little time to give the requester their products, these labeled units have put a significant delay on that, and in my opinion, has deceased patient safety.

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16 minutes ago, Cliff said:

@SMILLER, we have always been able to determine who received our products, including all emergency release products.  We have a form the physician signs that lists the units.  The blood bank issues those products (when they have time) to that patient and we can track where every product goes.

What I take exception to is the inspector insisting that we also put the patients name and MRN on the product.  They again insisted this made the process safer.  It does not in any way make it safer, especially if it's a system assigned name / MRN and more importantly, when it takes a modest amount of time to generate these labels.

We have done a tremendous amount of planning to ensure we can give out emergency release coolers, almost on demand.  It takes us very little time to give the requester their products, these labeled units have put a significant delay on that, and in my opinion, has deceased patient safety.

HEAR, HEAR!

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16 hours ago, Cliff said:

@SMILLER, we have always been able to determine who received our products, including all emergency release products.  We have a form the physician signs that lists the units.  The blood bank issues those products (when they have time) to that patient and we can track where every product goes.

What I take exception to is the inspector insisting that we also put the patients name and MRN on the product.  They again insisted this made the process safer.  It does not in any way make it safer, especially if it's a system assigned name / MRN and more importantly, when it takes a modest amount of time to generate these labels.

We have done a tremendous amount of planning to ensure we can give out emergency release coolers, almost on demand.  It takes us very little time to give the requester their products, these labeled units have put a significant delay on that, and in my opinion, has deceased patient safety.

Well said, Cliff !

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21 hours ago, Cliff said:

@SMILLER, we have always been able to determine who received our products, including all emergency release products.  We have a form the physician signs that lists the units.  The blood bank issues those products (when they have time) to that patient and we can track where every product goes.

What I take exception to is the inspector insisting that we also put the patients name and MRN on the product.  They again insisted this made the process safer.  It does not in any way make it safer, especially if it's a system assigned name / MRN and more importantly, when it takes a modest amount of time to generate these labels.

We have done a tremendous amount of planning to ensure we can give out emergency release coolers, almost on demand.  It takes us very little time to give the requester their products, these labeled units have put a significant delay on that, and in my opinion, has deceased patient safety.

We do the same.  If we have a "Doe" patient arriving, we ask for the age and gender, then issue O Negative or O Positive packed cells depending on the answer.  These units are labeled only with an "Uncrossmatched Blood" sticker.  If, by chance, we have received a specimen prior to the need for uncrossmatched packed cells, we quickly do a blood type and will then issue type compatible packed cells with a patient identification sticker and "Uncrossmatched Blood" sticker on the units.  There is also the paper for the physician to sign acknowledging the need for the emergency blood.  These are sent in a blood cooler and are issued to the patient after the cooler is returned and we have paperwork showing the units were transfused.

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When we had our shooting here two years ago, we just handed out emergency release OP and ON PRBCs to the ER.  There was no documentation regarding these units, and we still don't know which patients received which units.  They did not ask for blood for a certain patient, just that they needed units.  One doctor charted that he gave a unit of platelets to a patient-we didn't issue any platelets.... To comment on Carolyn's post, if we have another mass casualty, we will send a med tech down to the ER with the products in boxes with ice, and the tech will coordinate with the nursing supervisor to make sure when we hand out a unit that a sticker gets put on that patient's chart.

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1 hour ago, mollyredone said:

When we had our shooting here two years ago, we just handed out emergency release OP and ON PRBCs to the ER.  There was no documentation regarding these units, and we still don't know which patients received which units.  They did not ask for blood for a certain patient, just that they needed units.  One doctor charted that he gave a unit of platelets to a patient-we didn't issue any platelets.... To comment on Carolyn's post, if we have another mass casualty, we will send a med tech down to the ER with the products in boxes with ice, and the tech will coordinate with the nursing supervisor to make sure when we hand out a unit that a sticker gets put on that patient's chart.

1)  Did any of what you did endanger a patient, rather than help a patient, because there was no documentation?.....and 2) (Tongue very firmly  inserted into cheek) how would sending down a med tech to the ER help, if you keep your platelets on ice?............................SORRY.

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49 minutes ago, Malcolm Needs said:

2) (Tongue very firmly  inserted into cheek) how would sending down a med tech to the ER help, if you keep your platelets on ice?............................SORRY.

Oh You!!  ER did return some platelets on ice not too long ago, with the whole massive transfusion pack of 4 PRBCs, and 2 FFP!  Obviously not needed!

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WOW@ this feed :P So, we've decided that we will start labeling them even if they are Jane/John Doe along with our "uncrossmatched" conspicuous sticker.  Name, DOB, and MRN should suffice, correct?

Also, there has been discussion of what type to give patients.... I know what you're thinking, but hear me out.

Normally, we give O-Neg no matter what. That's never been an issue, but a tech asked me if we could give type specific if it was a patient we had a confirmed history on. Another tech says that at her previous hospital they had to either give O Neg or they could give whatever type the patient was typing at that time. The AABB Technical Manual states " issue uncrossmatched blood if the patient's ABO group is unknown. Issue blood that is ABO and Rh compatible if there has been time to test a current spec." Well, if it's a person we've had before and there's no time to test a current specimen, and we have a confirmed type--can we technically issue whatever their historic type is? The manual doesn't speak to those we would know the type just from history.

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It has always been my understanding that you can not issue blood based on previous history!  I don't have the reference available but that was a standard we lived by for my entire 35+ years in the blood bank.  All too often we had people come in sharing ID/Insurance information and the first way we were alerted was when the blood types didn't match with the history we had.

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2 hours ago, EAB81 said:

The AABB Technical Manual states " issue uncrossmatched blood if the patient's ABO group is unknown. Issue blood that is ABO and Rh compatible if there has been time to test a current spec." 

This is the answer to your question:  a current specimen.  A historical blood type is not a current specimen!

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2 hours ago, BankerGirl said:

This is the answer to your question:  a current specimen.  A historical blood type is not a current specimen!

Agree. We don't issue type specific blood unless we have time to get a current type and perform an immediate spin crossmatch for ABO compatibility, and it's still issued as uncrossmatched until the antibody screen is done.

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