5.7 Group O Blood for non group O.ppt (1) · Microsoft PowerPoint - 5.7 Group O Blood for non group...

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Utilisation of Group O Blood For non‐Group O patients

Sahar EtesamBlood BankMater Health Services, South Brisbane


Wrong Blood In Tube

• In September 2015 at 2.34am a young female presented in Pregnancy Assessment Unit with SROM

• As part of the assessment process the Blood Group and Antibody sample (Group & Hold) collected by medical staff on the day of admission.

• The Crossmatch sample and FBC sample were collected and sent to the pathology

• The Blood Group and Antibody result of the patient:

B Positive – Antibody Screen Negative

• It was the first time that a sample from this patient had been submitted to the Mater Blood Bank.

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Wrong Blood In Tube

• The Patient delivered her baby later that day

• The patient experienced a PPH of approximately 2 litres following the delivery

• Patient had a Haemoglobin on Day 2 Hb= 80

• A repeat Hb was performed on Day three of PPH Hb=68

• The Blood Transfusion was requested due to anaemia on Day four

• 2 Units of Group B Positive were crossmatched by electronic crossmatch method

• The first pack red cells were issued to the ward at 12.30 on Day four PPH.

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Wrong Blood In Tube

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• The blood Bank received a call that the blood group mismatch had been detected.

• Patient recognised that the blood group on pack cells is different with her blood group!

• The patient’s chart was checked and there was a QML report indicating that the patient’s Blood Group is O positive!

• Patient did not receive the blood, further investigation revealed that doctor had collected blood from the wrong patient.


WBIT Data SHOT 2016

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There is an increase in the number near misses reports in 2016. 2016= 1283 2015= 1243


WBIT Data SHOT 2016

Number of WBIT among 881 cases that

leads to IBCT is 776

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Key SHOT Messeges

• Obtaining a second sample confirms the ABO Group of the first time patient prior to transfusion and prevent wrong blood in tube related incidents and also ABO‐ incompatible components being transfused (BSH Milkins et al 2013)

• Collecting more than one unit at a time or units for more than one patients can affects focus of person who collecting the blood and leads to error, collect one unit for one patient at a time where possible (BSH Harris et al 2017)

• Good communication and teamwork is essential for patient safety and transfusion safety

• Reasons for WBIT is poor practice which includes Patient not identified, sample not labelled at bedside, sample not labelled by person taking the blood and prelabelled bottle.

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Confirmatory Group Check Sample Policy

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Group Check Policy

If patient is not Group O (A, B or AB) and crossmatch has been requested

• Organising second blood group sample either

– Assessing FBC sample that collected on different occasion within 72

hours and it has to met the Labelling criteria

– Organising Mater collector to collect Group check sample

• If Unable to check Blood Group, the O group blood Neg or Pos ( age and

gender) is crossmatched.

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Effect on Group O usage

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Conclusion

• Patient identification prior to collection of the sample is absolutely important.

• Patient’s details on request form and sample should be checked and should

met the criteria of pre Transfusion sample.

• Based on SHOT messages, second sample should be requested to confirm the

ABO group of first time transfused patient.

• This request can decrease the number of Group o usage.

• Group O usage is affected by the new policy.

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THANK YOU

Date post:	20-Jul-2020
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5.7 Group O Blood for non group O.ppt (1) · Microsoft PowerPoint - 5.7 Group O Blood for non group...

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