ARNOT HEALTH POLICY AND PROCEDURE MANUAL POLICY #: …d2xk4h2me8pjt2.cloudfront.net/webjc/attachments/... · POLICY AND PROCEDURE MANUAL POLICY #: TR210.0 DATE OF ISSUE: 4/10/17 DATE(s)

ARNOT HEALTH

POLICY AND PROCEDURE MANUAL

POLICY #: TR210.0

DATE OF ISSUE: 4/10/17

DATE(s) OF REVISION: N/A

APPROVAL: ____________________________________

Dr. Yafei Wang M.D.

Medical Director of SJH Laboratory

____________________________________

Dr. Terence Lenhardt, M.D., PhD

Medical Director of AOMC & IDMH

Laboratories

Medical Director of Transfusion Services

FACILITIES COVERED:

AOMC AMS SJH IDMH

TITLE: Collection of Blood Bank Samples

ORIGINATOR: Laboratory – Blood Bank

PURPOSE

Positive patient identification is critical in the collection of blood bank samples. This procedure defines

the appropriate steps for collection of these samples.

The main steps of the process are outlined in this policy. There are unit specific workflows as appendices

SAMPLE REQUIREMENTS

Full Pink top EDTA tube, or a lavender microtainer for NICU samples

Lab Order label must be on the sample

Two collector codes must be on the sample

Home draw Patients must have Verification form completed

Time of draw must be on the sample

If any of the requirements are not met, the sample will be rejected and must be redrawn

PROCEDURE

1. Order for Type and Screen or Type and Crossmatch is placed in Quadramed

2. Obtain the lab order labels

a. If they are unusable, get lost, or can’t be used for any reason, contact the Blood Bank for a

replacement label

b. In the Event of computer downtime: Place a chart label on the sample with both

Quadramed Codes and time of draw written on it. THIS IS THE ONLY TIME IT IS

ACCEPTABLE FOR A BLOOD BANK SPECIMEN TO BE SENT WITH ONLY A

CHART LABEL. 3. Positive Patient Identification at Sample Collection


TITLE: Collection of Blood Bank Samples POLICY # TR210.0 Page 2 of 14

a. Two people must be involved in the patient identification at the time of sample collection

a. One of the two must be licensed (RN, LPN, MD, DO, PA, Nurse Practitioner or Med.

Tech from the Lab) b. Ask the patient their name and date of birth

c. For non-verbal patients, the patient’s family or Nurse must confirm ID

d. One person verifies the name and date of birth against the registration bracelet, outpatient

requisition or Chart Photo/MARS for SNF patients

e. The second person verifies the name and date of birth against the lab label

f. If there is ANY discrepancy between the patients verbal response, the label or the

Requisition/wristband STOP. Blood sample cannot be drawn until the

discrepancy is resolved. g. After positive patient identification, collect blood sample, write both QuadraMed codes on

the label and the time of collection

h. Place lab order label on the sample before leaving the patient

4. Send Sample to the Laboratory

5. Patients with no previous Blood Bank History

a. Patients blood type must be verified with a second sample drawn at a different time than

the first sample

b. For all nursing units/patient care areas EXCEPT the AOMC and SJH ER, every attempt

will be made to use a previously drawn lavender tube

c. A laboratory Phlebotomist will obtain the second sample for Emergency Room patients at

both AOMC and SJH

a. For outpatient testing that will not result in the administration of a blood product: a

second sample is not required. (Prenatal Blood Bank, Outpatient ABORh, DAT,

Antenatal Rhogam)

b. NICU:

All cord bloods that do not have a full cord blood workup ordered will have

a Blood Type Confirmation performed.

If the neonate needs blood in the future, the type and screen or type and

crossmatch must be drawn with the Double Verification process.

If a cord blood was not sent, every attempt will be made to use a previously

collected sample, but if one is not available a sample must be drawn. It will

just be a regular blood draw with a lavender microtainer and only one

QuadraMed Code. Chart Labels are acceptable. 6. If a sample must be collected:

a. The confirmation cannot be ordered in QuadraMed and will be ordered by the Blood Bank

b. The lab order label may be sent to the patient’s location or the sample may be sent with

chart labels in emergent situations

c. Confirmation Sample does not require 2 person verification, will be in a lavender or pink

tube and chart labels are acceptable

d. For patients that are difficult to draw, only a very small sample is necessary and can be a

fingerstick sample collected in a lavender microtainer

e. The patient will only be able to receive O Negative red blood cells until this confirmation is

complete – due to the precious nature of O negatives red blood cells, this sample should be

collected ASAP

7. Some areas of the hospital have work flows that are unique. Please refer to the appendixes for

department/nursing unit specifics



Appendix I: Regular Workflow (AOMC L&D, MAT, ICU, Med Surge Units)

Appendix II: NICU

Appendix III: Operating Room/Recovery

Appendix IV: Pre-Admission Testing

Appendix V: Outpatient Phlebotomy

Appendix VI: AOMC Emergency Room

Appendix VII: SNF/TCU

Appendix VIII: SJH Emergency Room

Appendix IX: SJH Infusion Center and Falck Cancer Center

Appendix X: SJH Mixed Medical and C4 Unit



APPENDIX I: General Workflow: ICU, Med/Surg, MAT, L&D



APPENDIX II: NICU Workflow



APPENDIX III: Operating Room/PAR Workflow



APPENDIX IV: Pre-Admission Testing (PAT) Workflow



APPENDIX V: Outpatient Phlebotomy Workflow



Appendix VI: AOMC Emergency Room



Appendix VII: Skilled Nursing Floor and Transitional Care Unit (TCU)



Appendix VIII: SJH Emergency Room



Appendix IX: SJH Infusion Center and Falck Cancer Center



Appendix X: SJH Mixed Medical and C4 Units



Appendix XI: Home Phlebotomy and Satellite Phlebotomy Draw Stations (Only 1

phlebotomist)

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ARNOT HEALTH POLICY AND PROCEDURE MANUAL POLICY #: …d2xk4h2me8pjt2.cloudfront.net/webjc/attachments/... · POLICY AND PROCEDURE MANUAL POLICY #: TR210.0 DATE OF ISSUE: 4/10/17 DATE(s)