Hello all,

 

I have had a unique situation occure the other day and I am having trouble finding any resources to prove my suspicions that this was not kosher. 

 

Situation was a nurse called a transfusion reaction and stopped the transfusion and brought the blood down to the blood bank.  We then questioned if the Dr called the reaction, which he/she did not.  After calling up to his nurse supervisor they decided the Dr was not going to call the transfusion reaction, just administer antihistamine and tylenol and then transfuse another unit.  Everythign is ok until this part...

 

When the transfusion paperwork came back, a new stop time was added on to it and the amount transfused was changed.  When my tech called up they informed her that they rehung the unit that they originally brought down for the "transfusion reaction". The nurse said that both the nurse manager and the physician OK'd them to rehang the unit.

 

Now that just seems off to me, granted there is risk in transfusing a different unit of blood, but there was known risk in rehanging the unit.  I am trying to look through the technical manual to see if there is anything regarding this but I have never experienced something like this before.  All information or opinions welcome!!!

I have heard about/read somewhere in the literature that, if anti-Le^a is in the circulation, and causes a mild, but immediate, transfusion reaction, the transfusion can be stopped whilst the transfused Le^a substance in the transfused plasma, and the adsorbed Le^a antigen on the transfused red cells dissociates from the red cells, both "mop up" the anti-Le^a in the patient's plasma, the same unit can be restarted without further problems - but I wouldn't like to try this!  I have never been a huge fan of the in vivo cross-match!!!!!!!!

 

The practice you describe sounds highly dangerous to me.

        How did the blood get back to the nursing unit? Didn't you say that they brought it back to the Blood Bank? If so, we would not reissue a unit that has been spiked or returned to us. We have had the situtation where they have stopped the unit for a little while and then re-started the same unit but it wasn't brought back to the Blood Bank.

    

 

       I agree that I don't think that is a good practice and is highly dangerous.

As you know, according to the Technical Manual if it was urticaria only and they stopped to medicate, the unit can be restarted, but the key is that it was never disconnected. Plus the unit must be infused within the original four hour window. In your case the unit was 'unhooked' and taken to the lab and returned to the floor - was contamination of the unit possible because it was no longer connected with the infusion set and had to be reconnected once returned to  the floor? (I'd say yes - more messing, more potential for contamination), was the patient re-identified before the unit was rehung?(I'd bet not), did the infusion time exceed the original 4 hours?

 

Sounds like a really bad idea to me. I would say no to rerelease if my staff called and asked about it. I would take the incident to safety huddle and fill out an occurrence report. But can I point to something in the literature that supports me for this specific case - no, just a gut feeling. Bad vibes!

When i say they brought it back to the blood bank, they walked into the blood bank but my tech did not take the blood, the nurse had the blood when he walked in, and it never left his hand and he took it back to the floor.  This was just an unusual situation and she didnt think to take the blood from the nurse, granted it would have been best to.  But it was not "returned" and then reissued that would be a huge violation.

 

We cannot prove that the reidentification occurred or did not occur, its his word against ours with that.  And the unit was transfused in the 4 hours.  Bacterial contamination and the risk of transfusing the rest on the incorrect person are our two biggest issues with this.  But as I said, I have not found any documentation where it says do not stop and unhook a transfusion and then rehang and start it again.

 

I agree, this has bad written all over it, just too many potential safety issues that are being discarded, but what is my staff suppose to do, get in a fight with a nurse if he won't hand over the blood.  Disturbing is the nurse supervisor AND physician ok'd the unit to be rehung!?!?

I think this is a current standard, check out 1) :

AABB Standard

 5.18.4 Reissue of Blood, Components, Tissue, and

Derivatives

Blood, components, tissue, or derivatives that have been returned to the blood bank or transfusion service shall be reissued only if the following conditions have been observed:

1) The container closure has not been disturbed.

2) The appropriate temperature has been maintained.

3) For red cell components, at least one sealed segment of integral donor tubing has remained attached to the container. Removed segments shall be reattached only after confirming that the tubing identification numbers on both the removed segment(s) and the container are identical.

4) The records indicate that the blood, component, tissue, or derivative has been inspected and that it is acceptable for reissue.

—AABB

Scott

Yes SMILLER but that is talking about reissuing.  At no time was this unit reissued.  It was never returned to blood bank, so this would not apply to this situation.  We would never have accepte this unit back under the current conditions of it being spiked.  The nurse never handed over the blood when he walked down with it.

I agree with everything Ann stated above.  The only real problem is that the unit was disconnected, and removed from the patient.  Everything else that was unacceptable occurred after that.  Obviously, at this late date, there is nothing you can really do but consider this a wonderful opportunity to educate a few nurses.  Good luck with that! 

I'm with John - education is needed. Can you take it to Quality? They should be able to address both the physician and nursing side of things. Physicians don't really know all that much about transfusion/blood bank issues other than writing orders to transfuse. They whys and why nots are not addressed in their training process. I think that in the situation you described a quick call to the pathologist on call would be a good way to address the problem without doing battle. The pathologist can educate the physician on the spot (or at least tell him/her - "No, you can't rehang the blood and here's why") and your staff member can say "sorry, the pathologist says no".

"When i say they brought it back to the blood bank, they walked into the blood bank but my tech did not take the blood, the nurse had the blood when he walked in, and it never left his hand and he took it back to the floor."

 

Keep in mind that I am a cranky old Blood Banker,    , but if that unit came back in someone's hands and had been spiked, I would not let them leave with it.

 

Like the seagulls in the film "Finding Nemo" MINE!!!

 

Beth

Edited August 20, 201410 yr by EDibble

I'm with Beth, he/she would not have left the Blood Bank with the unit!!!

Are you accredited by the Joint Commission? They have a reg that states the physician cannot restart a transfusion if a reaction is suspected.

TBOSTOCK, we are accredited but the physician did not call a transfusion reaction.  We actually got more info the other day.  The nurse misunderstood the doctor.  The doctor told him to stop the transfusion, give meds then restart in an hour.  He took it as he was calling a transfusion reaction and stopped and unhooked. 

 

Still not a kosher situation but everything was cleared up, the nurse knows he didnt do it what he was supposed to do correctly. 

 

And I agree that he shouldnt have left the blood bank with that unit, but lab staff have got in trouble by questioning doctors and nurses before so they hesitate to take something out of someones hands. 

and AMcCORD, my staff did not know they were going to rehang the unit.  She thought they were going to discard the unit on the floor, which they did not.  If she knew they were planning on rehaning she might have been more proactive on not letting him leave and she would have called either more or the pathologist.  From the way the nurse talked it sounded like they were going to discard but then when she received the transfusion paperwork back she saw time and amount transfused edits and called to ask why.  Thats when she found out.

and AMcCORD, my staff did not know they were going to rehang the unit.  She thought they were going to discard the unit on the floor, which they did not.  If she knew they were planning on rehaning she might have been more proactive on not letting him leave and she would have called either more or the pathologist.  From the way the nurse talked it sounded like they were going to discard but then when she received the transfusion paperwork back she saw time and amount transfused edits and called to ask why.  Thats when she found out.

 

It always amazes me how much nursing staff and physicians think we don't need to know or can't fathom why we would even care. Heavy Sigh!

Does your nursing policy for transfusions need to be ammeded to cover interruption in the transfusion process? People do drift into habits of "doing their own thing". If the physician becomes involved, can you refer them to your medical director? We invoke the name of The Joint Commission and that helps. The AABB doesn't mean anything to non-lab staff.

Things like this are tricky. We have something of a convoluted transfusion reaction reporting procedure that was developed in collaboration with physicians and nurses.  Briefly:

 

If an RN observes signs/symptoms of a possible reaction they will hold the transfusion, provide appropriate supportive care, and let the blood bank and physician covering the patient/unit know.

The physician can decide to continue or discontinue the transfusion.

In either case, specimens are collected and worked up stat in the blood bank. If the transfusion continued, they bring the infusion set to us after it's complete. If evidence of hemolysis/incompatibility are identified the blood bank is supposed to contact the unit immediately.

Joint Commission standards state that if reaction criteria are met, the transfusion reaction must be reported to the blood bank "even if the physician deems it unnecessary" so our doctors don't get to decide whether to call something a reaction.  They still try to convince nurses not to tell us but we are making some progress.

 

Heaven knows they have said things like "hypotension can't be a transfusion reaction" and "how could they have a reaction to their own blood" (for autologous).  Now I have a doctor who wants to know why we insist on drawing his frequently transfused patient every 3 days, "her blood type isn't going to change."  Even after we gave him the standards he wanted a reference for the reasons behind the standards.  Maybe immunology hadn't been discovered when he went to med school.  Sigh...

Just as a point of interest, is the patient OK?

Joint Commission standards state that if reaction criteria are met, the transfusion reaction must be reported to the blood bank "even if the physician deems it unnecessary" so our doctors don't get to decide whether to call something a reaction.  They still try to convince nurses not to tell us but we are making some progress.

 

Mabel, do you have the JC standard number for that?  Our policy states that the doctor can decide whether to call a reaction or not and we're lucky if they even call us!  They are inspected by JC so it would carry more weight in getting that changed.

 

Thanks,

 

Mari

QSA.05.18.01

EP 2 Bullet 5

_… suspected transfusion-related adverse events are reported immediately to the laboratory, whether or not the physician responsible for the patient deems it necessary to report the event.

We also are under Joint Commission and Ireland's own AML:BB regulations (from Eu Directives) and this would DEFINITELY not be allowed.

They can halt a transfusion until medical examination - if say just a mid allergic reaction, drugs can be administered and the transfusion re-started. Bloodbank or on-call scientist must be informed, but if the unit came down it would not be released back up to the ward.

 

Sounds like you need a strong medical director of transfusion services (mandatory here) and they would put a halt to stuff like satff being afraid of consultants etc.

 

Cheers

Eoin

Just as a point of interest, is the patient OK?

Yes, there was not any negative results from this.