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Fort Hood MASCAL . Lab Lessons Learned. 1LT Misty Youngblood March 25, 2010. Objectives. Identify the sequence of events that occurred during the MASCAL Evaluate the current MASCAL procedures in use at Medical Treatment Facility

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fort hood mascal

Fort Hood MASCAL

Lab Lessons Learned

1LT Misty Youngblood

March 25, 2010

  • Identify the sequence of events that occurred during the MASCAL
  • Evaluate the current MASCAL procedures in use at Medical Treatment Facility
  • Recommend improvements to the current procedures related to a MASCAL event
the first 2 hours 1330 1530
The first 2 hours1330-1530

19 - Emergency release Requests

3 - Blood Product shipments received

2 - Bodies admitted to morgue

2 - Blood Product inventories completed

- EOC established




the next 5 hours 1530 2030
The next 5 hours1530-2030

26 - Emergency BP Requests

6 - Blood Product Shipments

4 - EOC meetings

1 - Body admitted to morgue

- Employees released ~2000 hrs




overnight 2030 0830

5 - EOC meeting every 1-3 hours

10 - Bodies admitted to morgue

Final BP shipment ~2345 hrs




  • 45 Emergency Requests
    • 16 patients & 138 Blood Products
    • 126 transfused
  • 10 shipments of BPs
  • 13 Bodies admitted to Morgue
dept hospital aar s
Dept/Hospital AAR’s
  • “Top Six” that affected Laboratory Operations
    • Patient ID
    • BP Inventory Management
    • Communication with Transfusion Services
    • Morgue
    • Staff knowledge of BP administration policies
    • Specimens no orders/not labeled
issue 1 patient id
Issue # 1Patient ID

3 “systems” to ID patients

#1 - MASCAL pack – PAD, pt accountability

  • Stored in PAD
  • Blue armband w/# to track pt movement
  • Not for clinical/treatment purpose
  • Not registered in CHCS
patient id cont
Patient ID (cont)

#2 - Trauma pack – ED, clinical data

  • Forms stored in ED
  • No armband, no preprinted pt ID’s
  • Pt ID’s not registered in CHCS
  • Could not find immediately
patient id cont10
Patient ID (cont)

#3 - John Doe registration in CHCS

  • Used for unidentified trauma patients
  • Pts registered in CHCS upon arrival
  • Cannot be pre-registered - PAD issues
    • No preprinted ID bracelet/labels
  • Too slow for true MASCAL - not used
patient id consequences
Patient IDConsequences
  • Patients transported without ID bracelet
    • Pt’s ID in ER, OR, ICU & PAD did not match
  • Poor documentation and tracking through Patient care
patient id consequences12
Patient IDConsequences
  • Inconsistent patient ID
    • One pt had 14 different pt IDs
      • MC1 & MC3, 3 different SSN last 4, room #, different name spellings
    • MC4 – ID for 2 patients (3S & ICU)
  • BP reconciliation took 3-5 working days
  • Type specific blood could not be used
patient id recommendations
Patient IDRecommendations

Meeting - PAD, ED, DPALS, Business Ops

  • Create one “system”
    • Use for unknown trauma pts and MASCAL
    • ED staff familiar with system because of more frequent use
    • Must be immediately available
patient id recommendations14
Patient IDRecommendations
    • 100 ED, 100 PAD (for DIME locations)
      • TRAUMA/MASCAL 001 with system generated-SSN
    • PATCAT 92 FMP98, DOB Field 2010
    • Embossing cards, armband and labels
    • Each form will have ID already stamped
patient id recommendations15
Patient IDRecommendations
  • Other Recommendations:
    • Need realistic MASCAL training
    • PAD added to ED’s emergency recall
    • Utilize only O RBCs
issue 2 bp inventory management
Issue #2BP Inventory Management
  • Multiple shipments of BP
    • Too many BPs received to process & store
  • Delay issuing Platelets
  • Post access
    • Couriers stuck in traffic trying to deliver BPs
bp inventory management the numbers
BP Inventory Management The numbers

Many BPs were shipped out 09-11NOV09

Not all locations wanted BPs back

Outdate rate for NOV 21% and DEC 16% (normal outdate rate <5%)

bp inventory management recommendations
BP Inventory Management Recommendations
  • Coordinate through Trans Svcs
  • Ask for Platelets early in the process
  • Have access control phone numbers readily available
lab status




Key Personnel Chief:


**58 total personnel present for duty



issue 3 transfusion service communication
Issue # 3Transfusion Service Communication
  • Techs- Emergency release and shipments
  • No one was trained to assist answering phones, inventory etc
  • Phone line was often busy
transfusion services communication consequences
Transfusion Services CommunicationConsequences
  • Miscommunication or misinformation to and from providers/nurses
  • Difficulty getting accurate and timely inventories to EOC
transfusion services communication recommendations
Transfusion Services Communication Recommendations
  • Emergency phone line - internal use during MASCAL
  • Designate and train additional personnel to:
    • Inventory BP including incoming shipments
    • Track BPs issued during MASCAL
    • Man emergency phone line
issue 4 morgue
Issue # 4Morgue
  • Procedural failures
    • Body admitted without body bag
    • PAD was not present
    • Body was not pronounced prior to admittance
  • Space
    • Morgue has room for 4 bodies
morgue consequences
  • Transport:
    • Morgue to truck
    • truck to truck – refrigeration unit failure
    • Smoking area near the loading dock
  • Justice of the Peace came to pronounce victim
morgue recommendations
  • Have litters available/know where to get them for easier, respectful transport and storage
  • Do not let emotions allow deviations from procedures
  • Designate team to assist with morgue functions
issue 5 staff knowledge of bp administration
Issue # 5Staff Knowledge of BP administration
  • Lab accused of not releasing FFP
    • Physicians did not realize they needed to request
    • Previous proposal by to Blood Utilization and Transfusion Committee to develop trauma pack for blood components was turned down
staff knowledge cont
Staff Knowledge (cont)
  • OR asked if blood issued to a patient could be used for another patient
  • Blood products issued to one patient transfused to another
    • BP issued to pt transfused to another pt (the only pt infused via rapid infuser)
staff knowledge consequences
Staff KnowledgeConsequences
  • Unable to issue type specific products
  • Reconciliation of paperwork
  • Animosity or accusations held against laboratory personnel
staff knowledge recommendations
Staff KnowledgeRecommendations
  • Establish Mass Transfusion policy
    • In conjunction with Blood Utilization Committee
    • Physician would have to request
  • Continue current policy
    • Pathologist monitor BP issued to individual patients
staff knowledge recommendations34
Staff KnowledgeRecommendations
  • Continue to issue only type O RBCs during MASCALs
  • Educate providers during Newcomers Orientation
issue 6 specimens no orders not labeled
Issue # 6Specimens No orders/not labeled
  • Multiple unlabeled tubes in bag with one label in bag
  • No electronic or written orders
no orders label consequences
No orders/labelConsequences
  • Lab personnel to ER to see what tests were needed
  • No ordering physician to contact for critical values
  • Chance for patient ID errors in reporting values increased
no orders label recommendations
No orders/labelRecommendations
  • MASCAL/Trauma registration
    • Provide preprinted labels, order via CHCS
  • Establish order sets
  • Use runners to communicate critical values if necessary
what went well
What Went Well
  • Rapid issue of BP – ready prior to the first request
  • Zero transfusion reactions
  • Donor Center delivered BP very quickly
what went well con t
What Went Well (con’t)
  • Supply clerk & NCO
    • Inventoried/Resupplied all areas
    • Coordinated pick up of BP flown in
  • Cytotechs automatically reported to Histology section to assist with morgue operations
  • Histology immediately called for and received trucks for additional morgue storage
what went well con t41
What Went Well (con’t)
  • Staff management - work rest cycles considered early and planned for
  • Food/drink provided to staff
  • Teamwork from all areas of the laboratory exemplary

Majority of changes/recommendations

involve two key elements:

Hospital policy for unknown Patient ID

Training and Knowledge base of staff