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Dr Paul Kerr Consultant Haematologist Royal Devon and Exeter NHS Trust 80% 70% 185 Cancer Services Directorate 60% 185 Critical Care 50% 185 Medical Directorate 185 Surgery I Directorate 40% 30% 185 Specialist Surgery Directorate 20% 185 W omen & Child Health Directorate Total 10% 0% Sep- Oct10 10 Nov- Dec- Jan10 10 11 Feb- Mar11 11 Apr- May11 11 4 3 2 1 0 Trained Untrained No record 50 45 40 35 30 Assessed 25 Not Assessed Unable to read signature 20 15 10 5 0 Doctors Nurses Phlebotomists Unable to read signature No further action accept risk More training Lab rejection of all samples from untrained staff IT solution eg Ordercomms 2 sample policy? Available Unavailable ABO mismatched transfusion frequently fatal Events are rare but considered unacceptable by the public and the DoH Wrong blood in tube events occur roughly every two months at RDE Training does not prevent near misses 95% of patients being transfused have had their blood group checked at least twice Request blood by phone or form: Historical sample exists Lab checks to see if historical group exists: Group Specific blood issued Request blood by phone or form: Lab checks to see if historical group exists: No historical Lab requests second sample be sent 2nd sample sent Group Specific blood issued Request blood by phone or form: Lab checks to see if historical group exists: No historical Lab requests second sample be sent 2nd sample not available and blood required Group O blood issued Engagement of staff involved in emergency care Group O always available Need for separate samples Highlighting of need to incident report issues If no 2nd sample after 10 units, use original Pragmatic response if antibodies on first sample Number of group and save requests BT Workload figures 16000 14000 12000 10000 8000 6000 4000 2000 0 Q1 Q2 Q3 Q4 Q1 2010-2011 Q2 Q3 2011-12 Date Q4 Q1 2012-13 Anecdotal evidence of taking one sample an splitting into two tubes Lab will reject these; care with labelling samples Quick audit suggested practice not rife Consider a situation where you are unable to take a second cross-match sample, for example during an urgent case where you are busy resuscitating an acutely unwell patient; what action should you take if the laboratory request a second sample prior to providing cross matched blood? Two sample policy introduced: No increase in O neg usage No increase in lab workload No increase in incidents/delay in blood Good communication needed Adherence to RPRB poor when medics take blood (Wrong blood in tube events appear to have fallen) Consider a situation where you are able to take a second cross-match sample; what action should you take if the laboratory request a second sample prior to providing cross matched blood?