with no second review and we do not perform Type Checks/Double Checks/2nd Types on patients.  We do have the two signature system when collecting.  That is our one safeguard.  Does this sound like a safe practice to anyone?

No!

No!

Just out of curiosity, how has this been working out for you?  Any significant problems or negative patient outcomes do to this practice?  What caused you to pose this question?  Also, how big and/or busy is your facility?  Is your testing manual or automated?  

On the surface I would have to answer your question with a NO but a little more info would help.  I've always been a "if it ain't broke..." kind of guy.  If your system is simple and works well for you why seek to complicate it.   

Edited June 6, 20187 yr by John C. Staley
additional thoughts came to me.

Regulatory requirements are pretty strict.  I would think that if you are following those, what you are doing is safe (and you have given us very limited information) .

Scott

Probably no - but more details would be helpful

19 hours ago, paddleking said:

with no second review and we do not perform Type Checks/Double Checks/2nd Types on patients.  We do have the two signature system when collecting.  That is our one safeguard.  Does this sound like a safe practice to anyone?

can we assume you are doing serological crossmatches  on everyone (which would confirm your 1 and only blood type, sort of)?  

I am not sure what more information you would need.  Here is a brief synopsis of errors I have witnessed or been informed of:

 

We have had wrong types entered.  On multiple occasions.  We have a vision so we should have it interfaced, but we had enter.  We have a large volume of T/S per day.  Between 75-125 depending on the day.  

We have had a Positive antibody screen entered as Negative and an IS XM performed when it was later found (on the same specimen, and totally by accident) that the patient had an anti-E.  Luckily when checking the two units that were transfused were negative for E.  

We have a specimens mislabeled.  Which leads to WBIT (Wrong blood in tube) and without a typecheck these cannot be caught.  And an serological (IS) will not pick these ups.  This, to me, seems to be the biggest issue. 

I was just curious.  This is a fairly new hospital I am working at and everywhere else we had a Typecheck system and instrument interfacing to help prevent these very preventable errors.  

When user enters Type and Screen results into computer, are intermediate results entered (anti-A, anti-B, etc) or only the interpretations, e.g. APOS, BNEG etc.?  Are results of Antibody screen for Cell1 and Cell2 entered or just interpretation, e.g. Positive or Negative?  

Edited June 6, 20187 yr by Dansket
Added more questions

We usually do test a specimen when we admit a patient the blood type, then inpute the result into the computer, where through network the doctor can see the result.When they ask for blood , they will write the first blood type result on the sheet, then we will recheck it through a new specimen for transfusion crossmatch.

Sometimes the first result is wrong due to wrongly specimen collection or other reasons, but most of the time it is right, and through this kind of process, we can find out the D neg blood type early( which is rare in Chinese Han people) and AB subgroup blood early before the blood application.

Edited June 7, 20187 yr by yan xia
typos

No. All manual entry at our hospital is reviewed by a second tech for typos

Hello paddleking:  I'm curious if you are AABB accredited or inspected by CAP or ???  Does your hospital have a patient safety reporting program?  Does your laboratory have a QA unit and/or event management system?  Seems like there are many processes out of control...

On 6/6/2018 at 6:07 PM, paddleking said:

I am not sure what more information you would need.  Here is a brief synopsis of errors I have witnessed or been informed of:

 

We have had wrong types entered.  On multiple occasions.  We have a vision so we should have it interfaced, but we had enter.  We have a large volume of T/S per day.  Between 75-125 depending on the day.  

We have had a Positive antibody screen entered as Negative and an IS XM performed when it was later found (on the same specimen, and totally by accident) that the patient had an anti-E.  Luckily when checking the two units that were transfused were negative for E.  

We have a specimens mislabeled.  Which leads to WBIT (Wrong blood in tube) and without a typecheck these cannot be caught.  And an serological (IS) will not pick these ups.  This, to me, seems to be the biggest issue. 

I was just curious.  This is a fairly new hospital I am working at and everywhere else we had a Typecheck system and instrument interfacing to help prevent these very preventable errors.  

If I am reading this correctly, it seems as though you have a number of chronic problems there,  In the US, I would think your lab would be in violation of a number of standards. 

Who are you regulated by?  Those are your MINIMAL guidelines.  In addition to following those standards to the letter,  your facility will need to address some other things, like--why are you seeing WBIT and specimen mislabeling issues?  Your problems seem to go way deeper than whether or not  the work is checked after it is finished.

Scott

Anytime you add humans to the process you will have manual result entry errors and WBITs.   My suggestion is to document the errors and discuss with you one up and quality person.  You are doing a lot of TASs to warrant an interface IMO.  

6 hours ago, tcoyle said:

Hello paddleking:  I'm curious if you are AABB accredited or inspected by CAP or ???  Does your hospital have a patient safety reporting program?  Does your laboratory have a QA unit and/or event management system?  Seems like there are many processes out of control...

Not AABB, just CAP.  

On 6/6/2018 at 4:50 PM, Dansket said:

When user enters Type and Screen results into computer, are intermediate results entered (anti-A, anti-B, etc) or only the interpretations, e.g. APOS, BNEG etc.?  Are results of Antibody screen for Cell1 and Cell2 entered or just interpretation, e.g. Positive or Negative?  

All reactions.  From a printout from the Vision.

3 hours ago, paddleking said:

All reactions.  From a printout from the Vision.

Does user enter interpretations manually or does the computer generate interpretations automatically?

CAP requires verification of all manual entries - this is in the All Common checklist. Every one of those errors should be documented with investigation and resolution - this is also something that a CAP inspection should be looking at with every inspection. Is the rest of the lab having as many problems???

 

 

Edited June 13, 20187 yr by AMcCord

NO. Too many issues here.

If i am supervisor i would not be able to sleep at night.

1) why are you entering results manually? If vision is interfaced and someone is entering results manually, there should be a check pr report for you to see all manual entries.

2) also er check all manual entries by second tech. (As some one stated this is CAP and may be your STATE requirement.

3) Every WBIT must be investigated with RCA to fix the problem.

4) If you are in US some of these are report able errors to FDA and may be STATE.

5) Start documenting every issue immediately. 

The Vision prints a barcode of the specimen number on the results page.  In our BBIS (SafeTrace) we must scan the specimen number before entering results and if it is not the specimen recorded for the patient it won't take those results.  That said, in the year we had our Vision before it was interfaced we always rechecked that the manually entered results had been entered accurately.

Like your lab we do it manually the ebtering of result into the hospital information system, there were some mistakes in the past that has been resolved with second sample system, the rule we are using is two sample drawn by two sifferent nurses witg 30 mintues gap or more .. we are doing this until we interface the vision in the future 

2 hours ago, radwan1411 said:

Like your lab we do it manually the ebtering of result into the hospital information system, there were some mistakes in the past that has been resolved with second sample system, the rule we are using is two sample drawn by two sifferent nurses witg 30 mintues gap or more .. we are doing this until we interface the vision in the future 

I am curious about why the 30 minute gap between samples?