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Emergency Release Labeling


EAB81

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If the blood is labeled as uncrossmatched and placed in a cooler or monitored refrigerator, it should be acceptable to apply the patient's name and MRN at the bedside just before transfusion, in an emergency situation. If anyone is using a Bloodsafe refrigerator to store emergency uncrossmatched blood in an ER, the patient identity is established in the clinical area by clinical personnel. I do not see how this is different. Having a made up dummy name complicates the process if the name is not being assigned by patient registration. In a true emergency situation or mass casualty situation occurs, the most accurate means of identifying who received what would be at the bedside, especially if there are multiple patients receiving transfusions. A patient chart label could be applied to the Transfusion tag prior to start of the unit.

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If I am not mistaken, when a Bloodsafe unit is used, the system automatically records who the unit is being released to, as opposed to simply taking a unit out of a cooler or refrigerator.  For look-back and other purposes, identification information must be reliably retrievable afterwards as well.

Scott

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That is true but patient identity is still occurring in the clinical area. It is possible for the Bloodsafe to be misused. More units can be removed than indicated, or blood for more than one patient can be removed once the door is open. If the process is set up to readily receive the information from the clinical area, it should work as a downtime process as well. I worked for many years at a Level 1 trauma center that could not have gotten blood out the door if it had to have a patient name and MRN applied to the labels. We had to issue coolers on demand within 1 minute. MTP blood first cooler had to be issued within 5 minutes. We had to label the units as uncrossmatched with no name assigned in a cooler storage device. We were told who the recipient was at the time of cooler pick-up. We did document that on an issue log. The patient's hospital chart labels were applied to all emergency paperwork. We were never cited by any regulatory agency for the process.

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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?

We are level 1 trauma center and we are fortunate that we get specimen ASAP. And patient gets MR# and name.

I do not recall a incident in 15 yrs where we did not have name or MR# for patient. And only two cases we did not get specimen for a while and had to issue O red cells and AB plasma...

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On 11/29/2017 at 9:00 AM, EAB81 said:

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.

NO. Until you type current specimen, you need to give O red cells.

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On 12/2/2017 at 2:08 PM, Eagle Eye said:

We are level 1 trauma center and we are fortunate that we get specimen ASAP. And patient gets MR# and name.

I do not recall a incident in 15 yrs where we did not have name or MR# for patient. And only two cases we did not get specimen for a while and had to issue O red cells and AB plasma...

We have had the same experience with our Jane/Jon Doe system.  When patients are triaged in the field, our ER sets up the Doe and MR so that they are ID'd positively when they arrive.  Blood Bank always has warning, so often we can set up and have properly labeled units down there in a cooler when they arrive.  Additional policies regarding cooler sets for MTPs had to be set up a few years ago so we could establish our level 2 trauma designation. We have had no avoidable delays due to any of this.

Scott

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As EAB81 said, the AABB states, "Issue blood that is ABO and Rh compatible if there has been time to test a current specimen." If your policy is to test a second specimen drawn at a different time to confirm ABO/Rh if no history is avaliable, does the emergent release need make it possible to include a policy to have an exception under this circumstance? We currently only issue O packed cells and AB plasma until the second type can be performed.

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We do much the same as most, but we prepare in advance.  "Unknown, Patient" with a special ER-#### Medical record # in the lab system to allocate and print tags.  2 O Pos for males, 2 O Negs for females are kept on hand at all times.  

Unknown patients in the ER are banded with a trauma # only until they are identified.  The emergency release form the ER sends to us has this #.  All we need to do is hand write this number on the already printed tags and send to the ER.  30 seconds.  When the patient is identified and we get a real medical record #, we either merge or re-allocate.  Usually we can track/trace all units.

Specimens with only a trauma # are good as long as that the is the identification the ER/OR is using.  When name/MRN changes, we need a new spec.

We do enough emergency issue, that having units tied up tagged is not a problem.  This system works well for us.

We need 2 specs to confirm ABO.  We will issue group O rbc and AB plasma.

Edited by kate murphy
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  • 4 months later...
On ‎11‎/‎27‎/‎2017 at 2:41 PM, 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.

Brining back this topic haha, Cliff - We are in the middle of revising our process and I have a couple of questions.  I'm hoping to get some ideas we can use to better our process.  Your emergency release products:  Are they pre-tagged - with downtime handwritten forms that have the unit information or with computer generated forms with a fake trauma name/MRN?  Which LIS do you use? 

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On 5/3/2018 at 2:26 PM, BloodBanker80 said:

Brining back this topic haha, Cliff - We are in the middle of revising our process and I have a couple of questions.  I'm hoping to get some ideas we can use to better our process.  Your emergency release products:  Are they pre-tagged - with downtime handwritten forms that have the unit information or with computer generated forms with a fake trauma name/MRN?  Which LIS do you use? 

We use HCLL.  We have multiple sets of products in the fridge.  We attach a blood product requisition to each.  We can't pre-print the product info from HCLL onto the tag, but we can pre-print a 4x4 label with all of the product info and place that on the tag.  When they call us, we require the patient name / MRN, even if it's a fake name / MRN, then we print a patient label and add that to the requisition also.  Our Emergency release form is pre-filled out with the nit numbers, and we keep a bag of the segments from the units with each set, also pre-filled.  That way we do as little as possible when handing out the cooler.  We're a level 1 trauma center and get a fair number of trauma's or bleeders.

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On ‎05‎/‎05‎/‎2018 at 7:46 AM, Cliff said:

We use HCLL.  We have multiple sets of products in the fridge.  We attach a blood product requisition to each.  We can't pre-print the product info from HCLL onto the tag, but we can pre-print a 4x4 label with all of the product info and place that on the tag.  When they call us, we require the patient name / MRN, even if it's a fake name / MRN, then we print a patient label and add that to the requisition also.  Our Emergency release form is pre-filled out with the nit numbers, and we keep a bag of the segments from the units with each set, also pre-filled.  That way we do as little as possible when handing out the cooler.  We're a level 1 trauma center and get a fair number of trauma's or bleeders.

Interesting, thank you for the info!  OK - So let me see if I have a good picture of the process:

You can scan the units you want to set up as emergency release to print a label that you apply to the product requisitions (which at least saves you time/errors from writing that portion).  You have the emergency release form with the set (of lets say 4 units) with the numbers filled in.  When they call, you grab the pack out, write the name/MRN on the Emergency release form, all 4 product requisitions including label that gets applied to the actual unit.  The person who picks up the product signs the form, you make a copy?  and they take it for physician signature as well and returns the form with the cooler (making an assumption).

 

We had HCLL until about 2 years ago and are trying to update this process to make it faster.  We are also a level 1 trauma.. and our issue is remaking the MTP sets once the first one is out.  We want to make that faster, and in order to do that the whole process has to change. 

 

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3 hours ago, BloodBanker80 said:

You can scan the units you want to set up as emergency release to print a label that you apply to the product requisitions (which at least saves you time/errors from writing that portion).  You have the emergency release form with the set (of lets say 4 units) with the numbers filled in. 

Correct

3 hours ago, BloodBanker80 said:

When they call, you grab the pack out, write the name/MRN on the Emergency release form, all 4 product requisitions including label that gets applied to the actual unit.  The person who picks up the product signs the form, you make a copy?  and they take it for physician signature as well and returns the form with the cooler (making an assumption).

We print an ADT label and place that on the requisitions, no handwriting.  We hand write on the emergency release form.  That is a two part form.  We keep a copy and send the original to the requesting clinician.  They sign and return - or we have a resident hunt them down to get signed and returned.

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31 minutes ago, Cliff said:

Correct

We print an ADT label and place that on the requisitions, no handwriting.  We hand write on the emergency release form.  That is a two part form.  We keep a copy and send the original to the requesting clinician.  They sign and return - or we have a resident hunt them down to get signed and returned.

Awesome - ADT labels... interesting!  We don't have anything like this.  I'm going to check with phlebotomy to see what they use! 

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On ‎12‎/‎06‎/‎2017 at 8:32 AM, kate murphy said:

We do much the same as most, but we prepare in advance.  "Unknown, Patient" with a special ER-#### Medical record # in the lab system to allocate and print tags.  2 O Pos for males, 2 O Negs for females are kept on hand at all times.  

Unknown patients in the ER are banded with a trauma # only until they are identified.  The emergency release form the ER sends to us has this #.  All we need to do is hand write this number on the already printed tags and send to the ER.  30 seconds.  When the patient is identified and we get a real medical record #, we either merge or re-allocate.  Usually we can track/trace all units.

Specimens with only a trauma # are good as long as that the is the identification the ER/OR is using.  When name/MRN changes, we need a new spec.

We do enough emergency issue, that having units tied up tagged is not a problem.  This system works well for us.

We need 2 specs to confirm ABO.  We will issue group O rbc and AB plasma.

Kate -

This is a similar idea we looked at after observing the process performed at another trauma center.  It seems the major difference is you handwrite the number, whereas they go ahead and dispense in their system to this fictitious name/number at the time of pickup.  Nursing personnel attach patient labels to the tags at time of transfusion.  Do you all keep a list of already registered special ER-#### to use from?  Or do you have like 5 that you use over and over?  Which LIS do you have?  We use Cerner, trying to figure out the best way to preprint those product tags....

Also, do you use your Emergency Release form with the units so it's already pre-labeled with the units - then have it returned with physician signature? 

Thanks!

Christy

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Our traumas are assigned MR#s before they are arrived and given a doe name, it is usually a name of a car (Mercedes, Doe). The sex  is usually  known and the dob is the same for all patients (100 yrs old). The computer system we use (Cerner Millennium) allows us the dispense the units with a exception flag telling us the unit isn't crossmatched ,do we want to override and why (we pick emergency). A transfusion tag is generated but the area which usually states compatible says uncrossmatched and across the blank area of the tag which usually has special attributes(irradiated) there is a statement saying "emergency dispensed, uncrossmatched.  

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2 hours ago, slsmith said:

Our traumas are assigned MR#s before they are arrived and given a doe name, it is usually a name of a car (Mercedes, Doe). The sex  is usually  known and the dob is the same for all patients (100 yrs old). The computer system we use (Cerner Millennium) allows us the dispense the units with a exception flag telling us the unit isn't crossmatched ,do we want to override and why (we pick emergency). A transfusion tag is generated but the area which usually states compatible says uncrossmatched and across the blank area of the tag which usually has special attributes(irradiated) there is a statement saying "emergency dispensed, uncrossmatched.  

sounds neat and tidy.   No handwriting anything!

 

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On ‎05‎/‎14‎/‎2018 at 10:41 AM, slsmith said:

Our traumas are assigned MR#s before they are arrived and given a doe name, it is usually a name of a car (Mercedes, Doe). The sex  is usually  known and the dob is the same for all patients (100 yrs old). The computer system we use (Cerner Millennium) allows us the dispense the units with a exception flag telling us the unit isn't crossmatched ,do we want to override and why (we pick emergency). A transfusion tag is generated but the area which usually states compatible says uncrossmatched and across the blank area of the tag which usually has special attributes(irradiated) there is a statement saying "emergency dispensed, uncrossmatched.  

Thank you for the feedback!  We also use Cerner, so I'm very appreciative of any further assistance you can provide.  We switched to Cerner one year ago, so we are trying to find the best way to incorporate it into our process.  Going off assumption from your post:  You have units allotted for emergency with segments pulled but do not actually label them until emergency room/OR would call and say they need them or show up with the name/MRN.  You will Dispense using your emergency process then attach the printed labels?  Once you have dispensed, and the dust settles (patient identity is known and specimen received), you go into Correct Inventory/ Emergency-Dispense function and merge it with that patient? 

Question:  Do you keep the emergency consent form with you, pre labeled with unit numbers - or does the courier picking up the units bring it already signed?

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We use the BloodLoc system.  Anyone admitted as a patient gets one.  In a pinch we will transfuse based on the bloodloc code.  It only exists on the patient's arm band and blood bank tube.

When they can't wait, they a unit labeled as uncrossmatched - group O (Rh depends on gender and age).  As Cliff has reported out, if you are giving group O . . . Sometimes we never get a specimen.  In these cases, the BB Medical Director signs off on the request sheet  from the ordering MD.

During out trauma certification the inspector had no problem that there wasn't a patient designated label on the product.  When someone is bleeding out the paperwork has to become a secondary issue. I tell my staff - "give them the blood, bring the paperwork when it calms down (including the MD request for unxm rbcs.

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On ‎05‎/‎18‎/‎2018 at 11:30 AM, AMcCord said:

We use the FinalCheck system in the same way as David uses BloodLoc, and before that, a Typenex band. I've never had a problem with inspections using this kind of process. We see JC, CAP and CLIA.

Interesting!  I really like these systems.  How do you prepare your units for Massive Transfusion/Emergency Release Sets prior to patient arrival?  We are looking for a way to pre label (without handwriting) as much as possible before the call comes in.  We are AABB/CAP/FDA........ Oh my!

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We are still on paper, so no computer fix. We also don't see Mass Transfusion/Emergency Release often enough to have a pack designated and ready to go. If we get advance notification from the ED/department, we will pull the appropriate units. If the patient is known, we can label tags (by hand) with patient name, blood type unknown if we don't have a current specimen. Once the patient is in the ED and we have a band on them, we use the band as the patient's ID - can use a sticker off of the armband tail as the patient name with male or female and location until we get more information.

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  • 1 year later...
On ‎11‎/‎25‎/‎2017 at 11:10 AM, 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.

Hey Cliff,

What standard/checklist item were you cited against?

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We have built several different "dummy" patients that allow us to quickly get emergency-release blood issued - we routinely keep pre-labeled Group O RBC in the ER, OR, helicopter, and a remote satellite lab at a smaller rehab facility as well as units labeled for Massive Transfusion Protocol in the Blood Bank. We currently use a paper form where the actual patient name or Trauma ID and MRN is documented for our record keeping and traceability. 

TJC seemed to have the most interest in how emergency-released units were labeled last year during multiple rounds of inspections - they were happy with our system since it does allow tracking of units from issue to transfusion. DHEC was also interested but not as focused.

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On 6/27/2019 at 5:06 PM, tcoyle said:

Hey Cliff,

What standard/checklist item were you cited against?

QSA.05.10.01

The laboratory has policies and procedures for identifying donor blood and recipient blood.

2. Policies and procedures for identifying donor
blood and recipient blood include the following:
- The blood recipient's full name
- An additional patient identifier (for example, a
clinical record number, health care account number)
- A protocol for labeling of donor blood and recipient
blood, including securely affixing the label to the
units after crossmatching and retention of the label
on the units until the transfusion is completed

 

EP2
Observed in Individual Tracer at xxxxxxxxxxxxxx Hospital site for CLIA #(s) xxxxxxxxxxx.
During review of a tracer patient who had received blood uncrossmatched, it was noted that the six units
issued in a cooler to the ED had not been labeled with two patient identifiers. According to ED staff, they had
a John Doe system with a unique identifying number that they could provide to the laboratory at the time
uncrossmatched blood was requested but the laboratory did not label the units with these two patient
identifiers. The laboratory did not have a process to issue uncrossmatched blood in anticipation of a patient
(blood storage) that allowed for issuing and labeling of the units in the ED upon arrival of the patient prior to
administration.

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