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Strategies to minimize the use of pre-transfusion
blood specimens that contain the wrong blood in the tube
A blood banker at a Florida hospital is considering
putting centralized blood bank phlebotomy in place (i.e. phlebotomists
that work out of the blood bank and draw all of the blood
bank pre-transfusion samples for
the hospital), as well as requiring a second separately
collected blood sample for confirmation of ABO grouping for patients
who have only a single current ABO result on file. She
is aware of the discussions:
However,
she would appreciate knowing which institutions currently
employ either of the aforementioned practices.
The following comments have been received.
ADDENDA Nov. 24, 2007
1. A Transfusion Service Medical Director reports that at his teaching
hospital in the Metropolitan Boston area a "Failure
Mode Effect Analysis" group recently met to discuss strategies to minimize the
use of pre-transfusion blood specimens that contain the wrong blood in
the tube. He has graciously provided a synopsis of their policies:
- Should pre-transfusion ABO/Rh
testing be performed twice, and if so, on different
samples or by different personnel? In the absence of a
historical ABO/Rh record to compare against a current
sample's ABO/Rh result, they will confirm the ABO/Rh by testing
a sample in another section of the lab, provided that
the second sample was drawn at a separate time. Otherwise,
their LIS reflexs a request for a second sample to
be collected from the patient. Pre-Admission samples that were submitted
for type and screen only are not tested again on the day of surgery
unless an antibody is identified, or blood for crossmatch is actually
requested. They use a blood bank wristband and the band number is
required on the cross-match tube, but not on the confirmatory tube
(the "ditto
tube"). It doesn't matter if the same tech does the retype, but
it must be a on separately drawn tube.
- Preventing pre-transfusion
specimen labeling errors Specimens must be labeled
at the bedside. A former lab director pronounced
the "six foot" rule to label the
specimen within six feet of the patient. The Blood Bank Band is initially
applied at the time of collection. Their original blood
bank bands had a unique number with corresponding numbered
adhesive stickers to be affixed to the tube, but they
found some mismatches. They recently switched
to a band without stickers, so the phlebotomists have to write
the number on the tube. Legibility has not yet been a
problem.
- Who should draw blood specimens
for compatibility testing? They
have a limited phlebotomy staff, so many tubes are drawn
by nurses, housestaff, medical students and other paraprofessionals.
They require that anyone drawing specimens for
blood bank must undergo a competency training and evaluation,
though a discussion ensued that there should be a universal
standard competency for all phlebotomy specimens. The
Medical Students were of particular concern, because
they change over so frequently, with such brief stays,
that it would difficult to ensure their evaluation and
competence. Thus, Medical Students are not privileged
to draw cross-match tubes. A second point is that the
phlebotomist must be clearly identified by a
legible entry on the tube of first initial and
last name (or an employee number.) The Blood Bank really
doesn't have the ability to screen for those with Blood
Bank drawing privileges per se, but must have the ability
to identify who drew the blood. The policy also calls
for disciplinary action and a re-education plan
for any staff member responsible for a mislabeling event. Furthermore,
if the ditto tube is in error, e.g. a Hematology specimen,
this needs to be corrected. The responding colleague
adds that he has recently heard of some hospitals with
a policy to have two people sign a phebotomy
tube to
ensure patient identification, but they rejected
this policy. Finally, he suggests that colleagues refer to
the CAP Standard TRM.30575 requiring a plan to implement
a system to reduce the risk of mistransfusion for non-emergent
red cell transfusions.The link to this newly revised
Standard, including changes from previous is HERE (MS
Word File).
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