A network dialogue on the question of using a second blood sample to verify a patients ABO/Rh type

The following discussion between two colleagues was facilitated by the e-Network Forum. It is reproduced here to illustrate the practical problems involved in implementing a process change, and how one institution addressed them.

These colleagues 'e-Networked' on the transfusion safety issue of proper specimen identification and verification of a patient's ABO/Rh. A colleague from Pacific Northwest laments that after years of experience with sample labeling and patient identification errors she has come to the conclusion that it may be necessary to confirm a patient's ABO/Rh by testing a second independently collected blood sample, as discussed recently on this forum. She adds that it seems that others have reached this same conclusion and that perhaps it may be time to adopt such a process. Although her institution is in the beginning stages of implementing a barcode armband system, full implementation will take several years. She wonders if any colleague who has adopted an ABO/Rh verification process using a second sample would answer the following questions.

A colleague from California accepted her challenge and has provided the answers below. Here is their discussion.

Q1: How did you proceed with implementing such a process? Did you first take the idea to a Committee (i.e. transfusion committee) for approval?

ANSWER: 'YES, IT WENT THROUGH THE TRANSFUSION COMMITTEE.'

Q2: Did you have a trial period using only one nursing unit at first to see how the process would work?

ANSWER: 'NO. WE ACTUALLY INSERVICED ALL PERSONNEL AND STARTED UP ALL AT ONCE. WE INSERVICED PHLEBOTOMY AND BLOOD BANK STAFF, NURSES AND PHYSICIANS. (SOME OF THIS WAS JUST DONE WITH MEMOS, TO LET THEM KNOW ABOUT THE PROCESS, SO THAT IF THE LAB REQUESTED ANOTHER SPECIMEN, IT WOULD NOT COME AS A SURPRISE). THE MOST IMPORTANT PEOPLE TO INSERVICE (OUTSIDE THE LAB) ARE THE NURSES WHO MAY HAVE TO DRAW EXTRA SAMPLES, AND PHYSICIANS WHO FEAR THAT THIS PROCESS WILL DELAY THE AVAILABILITY OF RED CELL PRODUCTS. SINCE THE DOUBLE-CHECK ONLY REQUIRES AN ABO AND Rh AND NOT AN ANTIBODY SCREEN, IT TAKES ONLY 5 MINUTES OR SO, AND CAN THEORETICALLY BE COMPLETED BEFORE THE TESTING ON THE INITIAL SPECIMEN IS DONE. IF THE DOUBLE-CHECK TESTING HAS NOT BEEN COMPLETED, IT IS OUR POLICY TO ISSUE GROUP O RED CELLS. TO MY KNOWLEDGE, AT OUR FACILITY THE EXTRA TESTING OF THE DOUBLE-CHECK HAS NEVER REQUIRED THE USE OF GROUP O RED BLOOD CELLS.'

Q3: Do you obtain a recheck on all patients or only on patients who type Group A, B, AB?

ANSWER: 'WE DO NOT DOUBLE-CHECK GROUP O INDIVIDUALS, SINCE THEY WILL BE RECEIVING GROUP O RED CELLS, ANYWAY. SOME PEOPLE HAD "PROBLEMS" WITH THIS AT FIRST, WONDERING WHAT IF THE PERSON REALLY ISN'T GROUP O. HOWEVER, THE POINT OF THE DOUBLE-CHECK IS NOT TO PREVENT MISDRAWS, BUT TO PREVENT ABO HEMOLYTIC REACTIONS WHEN A MISDRAW OCCURS.

SOMETHING TO CONSIDER IF A PATIENT IS RECEIVING PLASMA PRODUCTS, AND THEY ARE NOT REALLY GROUP O, THE POSSIBILITY EXISTS THAT THERE WILL BE A HEMOLYTIC REACTION FROM THE TRANSFUSED PLASMA ANTIBODIES. THIS IS A GOOD REASON TO DO ABO CHECKS ON ALL PATIENTS. HOWEVER THAT EXTRA WORKLOAD WAS A CRITICAL FACTOR IN CREATING AN ACCEPTABLE "PACKAGE" TO THE LAB. SINCE THE MAJORITY OF PRODUCTS WE TRANSFUSE ARE RED CELLS, THIS IS STILL A BIG SAFETY MEASURE FOR US. WE MAY TRY TO IMPLEMENT A PROCEDURE WHEREBY IF GROUP O PATIENTS NEED PLASMA PRODUCTS, A SECOND SPECIMEN WILL BE NEEDED IF THERE IS NO HISTORICAL TYPE AVAILABLE.'

Q4: I placed an inquiry about this topic on another website. I was horrified to learn that those who collect blood have found a way to get around the requirement for a second sample collection. They collect two samples at the same time but label them with different times. Honestly, it never occurred to me that someone would do that. Do you have that problem?

ANSWER: 'TO MY KNOWLEDGE, WE HAVE NOT HAD PROBLEMS WITH THAT. BASICALLY, THE WAY OUR PROCESS WORKS IS THAT WHEN A REQUEST FOR TYPE AND SCREEN OR TYPE AND CROSS-MATCH IS RECEIVED, RECORDS ARE CHECKED FOR A PRIOR ABO AND Rh. IF THERE IS NO HISTORICAL TYPING, THE SPECIMEN IS PROCESSED. IF IT IS NOT GROUP O, A SECOND SPECIMEN IS NEEDED. THE SECOND SPECIMEN SHOULD BE DRAWN BY A DIFFERENT NURSE/PHLEBOTOMIST THAN THE FIRST, IF PRACTICAL. THIS HELPS PREVENT THE "YES, I ALREADY KNOW WHO YOU ARE, SO I DON'T NEED TO LOOK AT YOUR ARMBAND" SCENARIO. THE SECOND SPECIMEN MIGHT BE DRAWN BY PHLEBOTOMY OR NURSING, DEPENDING ON LOCATION OF PATIENT AND CIRCUMSTANCES. THE BOTTOM LINE IS THAT AT THE TIME OF INITIAL PHLEBOTOMY, THE NEED FOR A SECOND SPECIMEN IS NOT KNOWN. ALSO, THE SECOND SPECIMEN MIGHT BE OBTAINED BY A DIFFERENT PERSON THAN THE ONE WHO OBTAINED THE FIRST. THIS MEANS THAT THE OPPORTUNITY TO DO THE "DRAW TWO AND LABEL THEM AS DIFFERENT TIMES" SCENARIO DOESN'T PRESENT ITSELF OFTEN. ANOTHER THING WE DO IS, BEFORE WE CALL FOR A SECOND SPECIMEN ON A PATIENT, WE CHECK TO SEE IF WE HAVE ANY CBC OR OTHER SPECIMEN FROM THAT PATIENT THAT WAS DRAWN AT A DIFFERENT TIME. WE WILL DO A TYPING ON THAT SPECIMEN AND USE IT AS THE DOUBLE CHECK. THIS SAVES A LOT OF SECOND DRAWS.'

Q5: How long has your process been in place?

ANSWER: 'ABOUT TWO YEARS.'

Q6: Since starting the process have you had any near-miss occurrences involving an error due to sample collection.

ANSWER: 'WE'VE CAUGHT THREE AT OUR FACILITY.'

Q7: Do you charge the patient for the second typing?

ANSWER: 'SINCE WE PARTICIPATE IN AN HMO, WE DO NOT CHARGE THE PATIENT FOR THE SECOND DRAW OR TYPING. IF I WERE RUNNING A PRIVATE LAB, I PROBABLY WOULD NOT CHARGE FOR THE SECOND DRAW. ALTHOUGH IT'S FOR THE SAFETY OF THE PATIENT, IT REALLY PROTECTS AGAINST AN ERROR BY THE "SPECIMEN ACQUISITION PROCESS," WHICH IS A HOSPITAL/LAB LIABILITY. I WOULD NOT WANT TO TRY TO ARGUE WITH A PATIENT WHO DOESN'T WANT TO PAY FOR A SECOND DRAW. I ALSO DON'T KNOW IF THIRD PARTY PAYERS WOULD REIMBURSE FOR IT OR NOT.'

The following responses were received.

1. A colleague from the Los Angeles area posed this question for the California blood banker above : "If the patient is already in the OR, and the specimens are being drawn by an anesthesiologist, do you require two draws?"

Page 2

Submit comments to the e-Network Forum at enetworkforum@cbbsweb.org

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

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

Elizabeth M. St. Lezin, MD
CBBS e-Network Forum Associate Editor & Moderator