Problems with the ISBT labeled blood product

A blood banker at a U.S. hospital is concerned that the expiration date is not easy to read on ISBT labeled blood products. She finds this to be a huge annoyance for her lab, and a possible cause for error. Apparently the expiration date used to be located on the upper right (and easily visible on stored units) using CODABAR labels. On the ISBT labels, the expiration date is on the lower right location, and when these units are in storage, the expiration date is not easy to see by merely glancing at the label. She wonders if others have found it problematic for the expiration date to be in its new location. If so, what practical ways can be suggested to store blood so that the expiration date is easily visible, to facilitate storing the blood in the refrigerator so that the oldest products get used first? She concludes that having the expiration date easily visible is a major consideration for her lab and they are struggling with ways to get around the issue of the red cell expiration date not being easily visible when the units are on the shelf.

The following comments have been received.

1. A transfusion service supervisor in a busy hospital in Southern California agrees that the expiration date of ISBT labeled blood products is not easy to read when units are in storage. At his facility they place each unit into a plastic unit holder, which they call "blood feet". The units are placed in the feet so that the expiration date is showing, either at the top right for Codabar or at the bottom right for ISBT. He complains that it is a hassle to read the ISBT label expiration date, as the units in the inventory must be manually manipulated to read the expiration date when all they used to do in the past was a visual scan of a Codabar label for the unit expiration date. In their walk-in refrigerator the shortest expiration date units are stored on the shelf closest to the door and as one moves towards the back of the refrigerator the expiration dates are longer. In the regular upright refrigerators the units are stored on the shelf with the shortest dates always to the right hand side of the shelf and increasing expiration dates as one moves to the left. Because of their large inventory and frequent shipments of blood products the inventory is checked once each shift. It is the responsibility of the person doing the shelf check to arrange the units in expiration date order. Whan a blood bank technologist goes to select a unit of blood for crossmatch, they automatically go to the shortest date units (either at the front of the walk-in or on the right hand side of the shelf).
   
   
2. Another Southern California transfusion service supervisor echoes the comments of the colleagues above. She finds it ironic that this question was posed to the e-Network Forum, since she was thinking just the other day that whoever designed the ISBT labels does not work in a blood bank, nor did they consult with someone who does. But why be practical? Her work-around is as follows:
   1. Everyday she prints out a report (Inventory Activity) to look at all the inventory that expires within the next 7 days.
   2. She puts a bright green label on each short dated unit that says "Use First" on the top of the units and places them in the front of the drawers. The technologists know to select those units first when crossmatching.
   3. They remove the "Use First" labels before issuing the units.
   4. She tries to rotate the rest of the stock daily to make sure the shorter-dated units are towards the front, but sometimes the units go wandering during the day.

Another problem with the ISBT units is that the CMV-Neg barcode is now in the lowest portion of the label, below the expiration date. Even though her staff try to keep CMV-neg RBC and platelet units segregated, it doesn't always work. Since they cannot see the CMV-Neg designation at a glance they are placing small dark green "CMV-Negative" labels above the ISBT labels. This makes it easier to visually assess the CMV-Neg inventory.

ADDENDA August 16, 2008

3. Editors' Note: Readership may wish to be cautious in attaching additional labels to blood products. Aside from the regulatory complexity of additional labels, some inspectors report concern that chemicals from the adhesives may leach into the bag. Hence, institutions may want to verify the acceptability of stickers before implementing the above discussed practice of 'placing small dark green "CMV-Negative" labels above the ISBT labels'.
   
   
4. A Texas blood banker agrees that it is difficult to read the expiration dates of ISBT labeled red cell products, especially when the units are twelve in a row in a crowded refrigerator. She has considered putting the units in the refrigerator "upside down" so that the expiration dates are visible but "upside down". She comments that it is much easier to see the expiration dates on upside down units, so that this seems like a viable solution. She asks if anyone knows of a reason the blood can't "stand on it's head" in storage?
   
   
5. The CBBS Editor who is a Medical Director from a hospital where they don't drink coffee recounts his experience in reading an entire novel upside down: "It is pretty easy - with a little practice - to read words correctly upside down, but numbers are a different issue. I found myself transposing digits (e.g. confusing 12 with 21) and had significant difficulty with 6s and 9s." He goes on to point out: "It might be dangerous to make it harder to read numbers."

Editors' note: The reporting CBBS Editor might need to get out more.

ADDENDA August 29, 2008

6. The Texas blood banker who commented in posting #4 on August 16, 2008 that she has considered putting the units in the refrigerator "upside down" has tried 4 units "upside-down" and reports that really did not help matters. She acknowledges that she never got as far as the number transposing problem mentioned in posting #5, because the expiration date really is not on the bottom of the bag, just the lower right of the label which puts in about in the middle of the bag. When the bag is upside-down in the slot on the shelf, the expiration date is still below the edge of the divider and just as hard to see. She apologizes saying "Please scratch my idea of standing the blood units on their heads."

ADDENDA Sept. 15, 2008

7. According to Pat Distler, Technical Director of ICCBBA (attribution used with permission) ISBT 128 was very much designed by blood bankers. Indeed, only blood bankers were involved in the original design process. She adds that while recognizing that it is very convenient to have the date at the top of the label, there were several considerations that took precedence over convenience. She continues saying: "First, the label was designed to give information with the highest importance prominence. It was determined that the Donation Identification Number (DIN) and ABO/Rh should be given the greatest prominence, so they are at the top. Expiration date is a function of the product code, not the ABO/Rh. When the product code changes (e.g., the product is irradiated), the expiration date must also be changed. By designing the label so that the date was across from the product code, it allows the lower half of the label to be changed whenever a product is modified, without disturbing the upper half of the label. In the US, this is especially important. 21 CFR 606.121 (b) can be interpreted as saying you cannot over-label the ABO/Rh of the collecting facility. (This regulation states that the product code label may be modified, and information directly related to it—like the expiration date—but otherwise you cannot over-label the information from the collecting facility). Given this, if you irradiate a unit from another facility, it would be very difficult to use automated means to change the expiration date at the same time you change the product label if expiration appeared in the upper right corner. Next, by placing the expiration date across from the product code, the two bar codes can be concatenated. That is, the two bar codes can be read together as a single message. This is done for safety. It is possible, if the two are not concatenated, that the DIN, product code, and ABO/Rh from the first unit can be scanned. Then the person scanning is interrupted, sets that unit aside, and picks up the next unit. When he returns his attention to what he is doing , he sees on the computer screen that he should scan an expiration date. He does, but it’s from a different unit. The expiration date from the first unit was never scanned and may be incorrect. Is this likely? No. But it’s easy to concatenate and it eliminates this possibility. So, the designers of the label placed two pairs of bar codes in positions to be concatenated: the DIN and ABO/Rh, and the Product Code and Expiration Date." In her opinion it comes down to not everything can be at the top of the label. "DIN and ABO/Rh should be linked on the label to allow concatenation, and so should product code and expiration date. Despite the inconvenience this may cause, that is the reason behind the design. It’s one of those cases where safety took precedence over convenience. If the wrong expiration is assigned by the processing facility, no measures thereafter can fix it. Therefore it’s crucial that this information be correct and the design of the ISBT 128 label promotes this, at least in the opinion of the expert blood bankers that designed it more than a decade ago." Finally, when it was designed, she thinks it was believed that by now computers would be selecting the unit to be used. That didn’t exactly happen, but in 1994 it seemed likely.

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

Elizabeth M. St. Lezin, MD
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