ADDENDA Jan 24, 2005

26. A colleague in Ohio reports that her academic institution has now been performing verification ABO grouping on a separate specimen for well over six months for patients who do not already have an ABO grouping result on file in the transfusion service. Their biggest challenge is with pediatric patients who are difficult to draw. In addition, while at first her hospital exempted patients whose initial ABO result was group O from needing a second specimen for verification ABO grouping, this exemption led to confusion and hence they now require a second sample for all patients who do not already have an ABO group on file, regardless of their blood group. She emphasizes that this becomes important in Pediatrics when an error may lead to the transfusion of platelets or plasma of the wrong ABO group.

ADDENDA May 3, 2005

27. A California colleague reports that his hospital's current method for patient identification uses a wristband containing the patient's first and last name and medical record number. In order to identify a pre-transfusion sample, the above mentioned patient identification information, along with the date and time of the draw, and the initials of phlebotomist are handwritten on a label that is firmly affixed to the specimen tube. If the patient does not have a blood type on record in their computer system at the time of a request for blood products, a second specimen is collected to confirm the ABO/Rh of the patient (the two specimens must agree on the ABO/Rh). He reports that in the near future they intend to use a "unique armband system" for the transfusion service, so that in addition to the ID band placed on the patient by Admitting, the laboratory will also place a second ID band containing a unique ID number, to assure that the correct blood product is transfused to the correct patient. His question is, should they continue to draw a second specimen on patients who have no previous history, once the use of the unique transfusion service band is instituted?

ADDENDA May 4, 2005

28. A colleague in The Netherlands reports that it is required that pre-transfusion testing of previously unknown patients include an initial sample for ABO-Rh(D) typing, and that a second sample must be obtained at a different time to be ABO-Rh(D) typed. The results from the first sample are compared to the results from the second sample. The results must agree prior to issue of blood for transfusion. In case of ABO-Rh(D) discrepancies, both ABO-Rh(D) results are discarded and two new blood samples are to be ABO-Rh(D) typed. In emergency situations, until a first blood sample has been ABO-Rh(D) typed, only group O-Rh(D) RBCs are issued to all patients. In female patients, group O-Rh(D) neg RBCs and in male patients group O Rh(D)-compatible RBCs are issued until the second sample has been tested.

29. The Florida colleague who provided the information posted in the Addendum of Dec 28, 2004 has provided follow up about his institution's experience with institututing confirmatory ABO/Rh typing for all non-group O patients who do not have a historical blood type on file in their facility. He points out that they implemented this retesting protocol despite having a double arm band system in place for over twenty years. He feels that they made the correct decision, as the confirmatory testing has proven to be much more reliable than any labeling system. Given how much resistence some of us have encountered in getting confirmatory testing implemented, the California colleague whose situation is described in the May 3, 2005 Addendum should be grateful s/he already has this in place. He adds that recently they detected their first mislabeled sample by having confirmatory ABO/Rh typing in place. While still under investigation, they think that an ER nurse drew a pretransfusion specimen when inserting an IV and then handed the specimen to someone else with instructions to label it. Somewhere in that process the specimen was switched with an unlabeled sample from another patient. Both the printed hospital label and the handwritten transfusion service label appeared correct. The confirmatory sample (second specimen for ABO/Rh confirmation) submitted from the OR prevented an incompatible transfusion. His experience also demonstrates that when a handwritten transfusion service label is used, such a label can introduce scribal errors into the system that result in "unnecessary" redraws. Since his laboratory is 'unforgiving' with regards to illegible labels, they are piloting a simplification of a double label that would employ a second transfusion service alphanumeric identifier on the patient armband, compatibility sample and blood units, but that would not require handwriting of any patient demographics. Although their nurses hate the handwritten labels, they were not willing to eliminate the second identifier - even though the transfusion service medical director was willing to consider going to a single label once ABO/Rh confirmation was in place!

ADDENDA May 8, 2005

30. Suzanne H. Butch, MA, MT(ASCP)SBB of the University of Michigan (attribution used with permission) is of the opinion that having two blood types on file in order to perform an electronic crossmatch was designed to prevent errors within the laboratory. When initially designing her own process for the electronic crossmatch, she and her Michigan colleagues performed all of ABO and Rh testing manually and entering the result of each tube directly into the Laboratory Information System (LIS). The LIS then calculated a blood type based on tables. They progressed to performing one ABO/Rh on an automated typing instrument combined with a manual tube confirmation if there was no existing type on file for the patient. This was due to a lack of an instrument/LIS interface and the automated results were entered from an instrument printout into the LIS manually. As they have again re-designed their process for an instrument/LIS interface, they continue to want to perform two typings. These typings would be performed in two separate instrument runs. This would ensure a separate identification and aliquoting of the sample. Without this separation of identification and aliquoting of the specimen, they are not sure what is gained by doing two types. It would seem to be measuring the reproducibility of the test system, not confirming a patient’s type. Depending on the LIS some hospitals, this might create a computer problem. Doing the same test in the same run might cause a conflict because in the LIS, the ABO/Rh verification step would be processing two results from the same patient at the same time. The two results would be hitting the same patient file for verification of the current typing with previous typing. The system may have been designed to prevent a “user conflict”. Suzanne adds that there are advocates for the two ABO/Rh types to be performed on samples collected at different times. This proposal implies that we cannot trust specimen collection. If we cannot trust blood bank specimen collections, can we trust specimens collected for other laboratory tests? If not, then all laboratory tests should be done twice on separately collected samples. Mislabeled specimens, where the blood in the tube is not the blood of the patient identified on the label of the tube, is a dangerous sample in the clinical laboratory in general. A critical glucose or potassium value that is treated unnecessarily has the potential to cause significant harm to a patient. She further comments that we need to get at the root cause of specimen mislabeling, and we need to design/implement systems that are easy to use and limit the risks of getting the wrong patient’s blood in the tube. She feels it is wrong to single out pretransfusion testing specimens, because that implies that it is OK to mislabel other specimens. She believes that we need to label blood specimens the same way every time using the safest system possible for all specimens submitted for laboratory testing.

ADDENDA May 10, 2005

31. W. John Judd, FIBMS, MIBiol (Professor of Immunohematology at the University of Michigan - attribution used with permission) asks some rhetorical questions about the need for more than one specimen being tested for ABO before using an electronic crossmatch test: 1) "If you use a validated instrument, with validated positive sample identification, validated interfaces and validated interpretation tables, wouldn't repeat testing of the same sample for ABO/Rh be redundant? 2) If repeat testing for ABO/Rh is not redundant, does that mean that our validations must be prone to error!!??? All kidding aside, John asks a very important question which gets to the heart of the issue, namely, if it is required to test two independently collected samples as a requirement for the electronic crossmatch, shouldn't such a rule be applied to all types of crossmatching, and not just the electronic crossmatch?

ADDENDA May 11, 2005

32. A blood banker in Texas reports that her hospital uses a separate blood bank identification band system with unique peel-off numbers for transfusion recipients. She believes that because they use such a blood bank identification band system for pretransfusion testing and blood product administration that this system acts as a "barrier" to ABO incompatible transfusion. She feels that if the wrong patient were to be drawn, the unique labeling of the pretransfusion blood sample would would prevent the inadvertent transfusion of ABO incompatible blood to the wrong patient, because the true intended recipient would not have the same peel off number assigned to them. She believes that such an error would be caught, a new specimen would be submitted, and the testing would be repeated for the correct patient. Thus, in her opinion, she thinks that by using their separate blood bank band system that a second ABO test from the same banded blood specimen tube fulfills the requirement that the ABO should be checked twice for patients when no previous ABO grouping result is available.

33. A transfusion medicine physician in Southern California who is about to retire after a 26 year career as a Blood Banker says that he finds this topic "a bit sad". He adds (quote) "It is true that we have made great strides in detecting viruses, bacteria and parasites, but the greater problem still persists, namely giving the patient the wrong type of blood. Correct me if its not true that more patients now die every year from receiving the wrong unit than from acquiring an infectious disease? The double sample or double testing may satisfy us blood bankers, but if I look at it from the patient's perspective, I would feel safer if there was a method to assure that no ABO mistakes take place at the bedside. I remember vividly the bedside crossmatch done on a tile at a poor hospital in South America in 1972. Is there any institution doing anything like this today?"

ADDENDA May 14, 2005

34. A colleague in Florida (see ADDENDUM #29 of May 4, 2005) cautions against placing great faith in a separate transfusion system labeling system to serve as a "barrier" to prevent/detect ABO errors, as proposed by the Texan in the May 11, 2005 ADDENDUM #32.  The Floridian reports that they used to use a similar (if not the same process) as that of the Texan, and that there were lots of ways such a specimen labeling system could be undermined, particularly if busy nursing personnel did not adhere to strict procedures. The Floridian reports that he recently attended a presentation by a "bloodless medicine" advocate who directs a transfusion service that transfuses over 50,000 units a year, who indicated that 2 or 3 times a year they discovered erroneous historical blood types! While citing this fact as a reason to avoid transfusion, the bloodless medicine advocate still thought requiring confirmation of the patient's ABO/Rh from a second sample was too onerous to be accepted by his nursing and medical staffs. The Floridian believes that each transfusion recipient should have their ABO/Rh confirmed regardless of the kind of crossmatch that is done (antiglobulin, immediate spin or electronic). He wonders when the rest of the blood banking community and the regulatory agencies will recognize this.

35. James P. AuBuchon, MD (Professor and Chair of Pathology at Dartmouth-Hitchcock Medical Center; attribution used with permission) comments that the use of the term "barrier" (see ADDENDUM #32 of May 11, 2005) with respect to preventing a mistransfusion has heretofore been restricted to a system or device that presents a physical barrier to mistransfusion if one is about to occur. (See prior e-Network Forum Discussion: Experience Using the Blood-Loc and Other Barrier Systems to Prevent Transfusion of Blood to the Wrong Patient.) The use of special labels, while possibly helpful, do not require that attention be paid to the discrepancy and the impending disaster. Thus, Dr. AuBuchon would prefer not to afford the use of special labels with the same prominence or distinction as a barrier system nor to depend on special labels to the same extent. Dr. AuBuchon offers an anecdotal confirmation: Digital electronic systems that provide a bedside label based on the patient's wristband and that can compare the intended recipient of a unit as stated on the unit's label with the wristband of the recipient are undoubtedly helpful in reducing mistransfusions. However, even they should not be regarded as a true "barrier". Several years ago, one of the anesthesiologists at Dr. AuBuchon's hospital worked with programmers of a (commercial) handheld device with the goal of streamlining the logic that it used during the pre-transfusion matching process. The programmers were able to deliver to the anesthesiologists a prototype that exactly met their specifications. Less than 5 seconds were required to read the information on the unit and patient, and receive confirmation that the unit was intended for that patient. The programmers then reportedly smiled, and asked the anesthesiologist, expectantly, "Would you then be interested in acquiring this system for use?" Much to Dr. AuBuchon's surprise, the anesthesiologist answered "No." Why not? According to the story, the anesthesiologist said: "Because we wouldn't have to use it." Apparently, the anesthesiologists were so used to the mechanical barrier system in place at the Dartmouth-Hitchcock Medical Center, that they were reluctant to rely on a system that would not force them to pay attention to the identification process. In a pinch, the anesthesiologist explained, they would just blow by the electronic system, take a quick glance at the label, and move to transfusion. Dr. AuBuchon appreciated their honesty, and his hospital has kept using the mechanical barrier system. He fears the same may be true with augmented identification systems, such as an additional number added to the wristband: Staff do not have to pay attention to it, or, even if they did, may see what they expect to see.

ADDENDA Sept. 21, 2006

36. The Editors believe that colleagues will find the data and experience reported in the article "Nearly Two Decades Using the Check-Type to Prevent ABO Incompatible Transfusions: One Institution's Experience" to be germane to the discussion.

ADDENDA Sept. 29, 2006

37. A colleague in the Pacific Northwest reports that her institution implemented the process of performing a 'typecheck' on non group O patients with no historical blood type 15 months ago and have subsequently prevented two mistransfusions because of the typecheck process. One potential mistransfusion would have been caused by a WBIT (wrong blood in tube) and one would have been caused by a medical technologist using a wrong sample for compatibility testing. Implementation of the typecheck process followed determining the impact this would have on the blood bank workload, transfusion committee approval, executive committee approval, flow charting the process, writing the procedure, training, implementation and monitoring the process. She reports that they implemented the typecheck process approximately one year before implementing an electronic crossmatch procedure. Having the typecheck in place has made their transition to an electronic crossmatch very smooth, although she acknowledges that it is not a requirement for electronic crossmatch implementation to repeat the patient's ABO/Rh on a separately collected sample. She adds that in spite of extensive efforts over 8 years by her hospital to improve patient and sample identification, they continued to have an unacceptable number of WBIT events. They could not make individuals follow the procedures 100% of the time, and finally felt that in their environment it was necessary to implement the typecheck process.

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator

W. Tait Stevens, MD
CBBS e-Network Forum Assistant Editor & Moderator