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If you feel that you are not being heard or appropriate action is not being taken you have the option of reporting to your accrediting agency AABB, CAP, TJC. This can also be done anonymously. The agency will contact the lab for information/investigation. If patient safety is being put at risk then you need to do everything you can to get these situations addressed which it sounds like you are doing. The other thing I would highly recommend is that you keep written/hard copy documentation of everything. You may need it sometime in the future to have proof of your diligence in trying to force compliance. Always remember the old adage "If it's not in writing, it never happened" Good luck

Our Deviation from SOP form is pretty simple.: Tracking # (a sequential # which I add when I review the form) Patient ID information Date/time of occurrence Description Reason for Deviation Action Taken - this is most often information completed by the tech who is responsible for the deviation or who discovered/corrected the deviation. Sometimes it is more appropriate for me to complete this part. I may add information to Description/Reason/Action sections. The medical director may add to any of these sections, though usually doesn't. Reported To/By/Date and Time Tech - person completing the report. This is usually the person who reports the occurrence, but not always. Signature lines for Supervisor and Medical Director Comment section - used for additional information or comments regarding the occurrence. This section is not always needed but is completed by myself (supervisor) and/or the Medical Director when necessary. This would be where I note retraining, disciplinary actions, whether or not a hospital occurrence report or safety huddle report was made, BPDR# if filed, calls to providers, etc. The Medical Director will comment on appropriateness of the deviation or contacts with providers as he sees fit. Example would be if the event was due to something like emergency release of uncrossmatched blood to a patient with an antibody. This form is one page and most of the events reported don't fill up all the spaces provided for entries. Once reviewed and addressed, I file them. I think if I was at a larger facility I would think about using a form online or at least a from that could be completed on our shared drive and emailed to me and the medical director. One of my goals is to build a spread sheet to track/trend by occurrence type - good quality project for my abundant spare time .

I am retired but volunteered several years as an AABB assessor. Both CAP and AABB send the deficiencies from the previous assessment to the assigned assessor with the submitted plan of action to correct the previous deficiency. Most plan of actions have a time frame documented to correct the issue. We were supposed to make checking completion of the plan of action a priority. My first question would be if this individual had completed any work before his training records were completed. Then, I would ask for his competencies that were completed during the allowed time frames. If I performed a tracer on your FDA reportable, could you provide completed training and competency records for all the employees who worked on that patient? Your pathologist may be young, but he does not want repeat deficiencies. Document everything!

Enjoy the attached from 20+ years ago. ABOincompatible.pdf

Agree entirely David (apart from the fact that antigens and cells cannot be homozygous, heterozygus or hemizygous, only genes can be termed as such). In the UK, of course, we do an enzyme panel in most cases, but I do agree that, in reality, r'r' and r"r" red cells are, in reality, only available to Reference Laboratories, and only then used sparingly (not least because antibodies that are that weak are rarely, if ever, clinically significant, either for HTR's or HDFN). My point, however, was that, from a serological point-of-view, unless you can perform Gm and Km typing of the antibodies, you cannot tell the difference between a passive anti-D and a weak allo-anti-D (and even that is not 100% reliable), you HAVE to rely on the patient's history as to whether or not she has been given prophylactic anti-D immunoglobulin, and whether or not there was any evidence of allo-anti-D in her circulation before she was given any prophylactic anti-D immunoglobulin.

Depends on a lot of factors. As for the assessors, you need to approve them to ensure there is not a conflict of interest, so you'll know exactly how many are coming. How big are you, what are you seeking accreditation for? If you have a donor center, and IRL, or another accreditation, it's likely you'll get an AABB staff member, otherwise, you'll get all peer assessors. While they are all trained to assess to the Standards, there is a lot if subjectivity. How many days also depends on your size.

Tomorrow is Thursday in the UK. I have the enormous pleasure of taking my wife out for her to do some shopping. Therefore, in case I forget in the fever of excitement I will be feeling tomorrow (ugh!), I would like to wish all of my friends who are either in, or are from the United States of America a very Happy Thanksgiving.

Ditto. We haven't 'split' a unit for a non-neonate for over 20 years! I agree with the above ... we'll just state what we do if we ever do get an MD who requests a split unit. I'd only add that the usual approach is for the MD to instruct the infusionist to 'Transfuse over 4 hrs.' vs the usual transfusion rate of 1.5 - 2 hrs. Eventually, hopefully, the CAP Checklist Team get the message that splitting the unit is not the only answer and shouldn't be unless it's done often enough to maintain competency, etc.

That is very sad. The final decision should depend upon a clinical discussion between the pediatricians, who know about babies, and the pathologists, who know about the value of the test results. No one discipline knows everything about everything.

I think what you are doing is acceptable. I am in the same boat. I had a procedure for splitting units but can no longer comply w the labeling regulations. I've never had an order and would recommend transfusing rbcs the same way you do.

This is a scan taken from Petz LD, Garratty G. Immune Hemolytic Anemias. 2nd edition 2004, Churchill-Livingstone. George may not have been medically qualified, but Lawrie Petz most certainly is, but the two of them were regarded as the world authorities in this kind of thing. The chapter on HDFN was added to the second edition. It was not in the first. It shows what a waste of time, money and reagents it is to perform a DAT on all babies born to group O mothers. This has not changed within the last 15 years.

You are not overreacting. You are being responsible, which is what all healthcare workers need to be. Other than discussing all of this with your department administrative director (your manager's manager -- maybe you have done this already -- at our hospital, this is at the department director level), I am not sure there is much else you can do within your department. You mentioned talking to the FDA and your risk management department. Your hospital should also have a corporate compliance fallback for things like this (that cannot be resolved through management -- you can report anonymously if you desire) For corporate compliance issues, the business must respond to your concerns and report back to you within a limited amount of time. Good luck. Scott

Ael? Or am I dating myself? I agree with Malcolm, for transfusion purposes, it doesn't matter what you call it. And ADsorption vs ABsorbtion ... I always looked at it this way: It depends on whether you are looking at the cell or the plasma. Antibodies are Absorbed from Plasma and Adsorbed onto RBCs.

A long time ago now, I was working in a very large London teaching hospital, when we received a patient who was a group B police officer (this was about the time when the IRA were active in London, but this case, as far as is known, ha nothing whatsoever to do with them). He had received multiple stab wounds. We soon went through our stock of group B, and eventually got through out stock of group O. Although we had ordered more stock to be delivered by "Blues and twos", at this stage we had a choice. We either transfused him with group A, or we let him die. The doctors in charge decided to give him group A. He survived, and when the emergency order of stocks has arrived, we switched back to group B, and then group O. Yes, his renal function was shot to pieces for a while, but, to be honest, that was probably the least of his worries at the time. I'm not saying that this would work every time, because it won't, but you can treat a haemolytic transfusion reaction, even an acute haemolytic transfusion reaction; death is difficult to treat. As Prof Brian McClelland MB ChB ND Linden FRCP(E) FRCPath (former Director of the Scottish National Blood Transfusion Service) once wrote in Thomas D, Thompson J, Ridler B. A Manual for Blood Conservation. 1st edition. 2005. tfm Publishing Ltd, "Transfusion has risks, but bleeding to death is fatal."! To my own shame, I once did a book review of this for the BBTS, and misquoted the title as, "A Manual for Blood Conversation."! The embarrassment!

End result: As I reread the thread I made an error - the Pathologist was the new "Medical Director" of the laboratory, we have a different person (MedTech) who is the Laboratory Director. Sorry about that. The problem resolved when the off site Pathologist resigned, and a new Pathologist who remains on site full time took the job - he will not be asking that we email photos of cells :)

This is why we treat all those weakly reacting anti-D patients as though the screen is negative and give them RhIG. It is safer even if the antibody is really a newly forming anti-D. Most of these are detected at the time of delivery so this baby is not at much risk from an immune anti-D of that low a titer. If the baby has HDFN, then we will proceed accordingly. If we pick up a weak anti-D and the patient received RhIG in the prior months but there is no record of a negative screen before the RhIG was given we will sometimes follow the patient for a few months to make sure the titer is decreasing rather than rising. We even have a test called SAB Rh Type that is for an Rh type and reflexes an antibody screen if the Rh is negative. That way we have a baseline antibody screen before RhIG is given which increases the odds that the anti-D detected later is passive.

The other thing could be that the clones used in the anti-D have changed, and they no longer detect a particular mutant type.

The answer to your first question is no. The answer to your second question is that there is no such thing as anti-A2, either natural or immune.

If we only do D typing on babies from D negative mothers and a weak D or Du test needs to be performed, the results of the weak D is only valid if the DAT is negative, so a DAT would need to be performed. Therefore, an ABO and DAT would be a good place to start. Just my thought.

To the elution question: if the results of the test will never alter the patient's treatment, it is hard to justify having the policy to always do the test, even if the results are academically interesting to understand causes and what is really going on.

Ah...but you have to carefully calibrate the use of that finger or fingers. And bare fingers worked better than gloved fingers. Of course, that was before we really had gloves.

Sorry, but that is almost certainly not a possibility anywhere, otherwise we would have all done it years ago. As I said above, if you give everyone group O red cells, because they can all have those (except Oh individuals, oh, and individuals with other antibodies than anti-A and anti-B), you will run out of the group O units you require for group O patients.

Thanks Malcolm, Thats great and very helpful.

Agree entirely

Very true Malcolm!!

It does bowerj1, except you are doing yourself, and the rest of us down. Peds never did "do" the babies of O moms. Most of them wouldn't have a clue how to "do" the babies of O moms. It is people like you, me and many thousands of scientists within the Blood Bank who "do" the babies of O moms.

Whether it is residual RhIg or a developing allo-anti-D we (on the front lines) still have to r/o C and E with the heterozygous cells. Granted, we can run w PeG or enzyme pretreated . . . to increase the sensitivity.

It is outside my window!!

Except that you don't have much choice to r/o anti-C or anti-E but r'r and r"r cells. We're talking RhIg anti-D, which is usually 1+ in gel

Sadly, it is not that easy. It is incredibly rare for an anti-D to show dosage, however, there can be noticeable differences in the strength of expression of the D antigen, even between individuals with the same Rh phenotype and, indeed, genotype.

I voted, but we actually do DAT only if the baby is positive for an antigen mom could have antibody to--Rh+ babies of Rh- moms and non O babies of O moms. I have tried for years to get them to drop the testing of babies of O moms but can't budge them.

We don't use just the cells that Ortho marks as an abbreviated panel for ruling out other specificities in the presence of passive anti-D. We add whatever other cells are required to have double-dose expression of the usual suspects. That said, we don't require double-dose K for ruling out anti-K on antibody screens so would not require it here. Also, we don't require use of double-dose E or C positive cells in the presence of anti-D, whether passive or immune, due to the low statistical risk to the patient.

I will preface my reply by saying I am not in a managerial position, just a tech in the lab. My facility has "Occurrence Reports" that record intentional deviations, reported errors, any workflow influence, etc. You can write them anonymously online or by hand. It's helpful at some points, but there's a fine line between people filling them out to report coworkers for silly things, or just filling them out when they feel "inconvenienced." I have a few problems with this process, but the form itself is outlined decently enough. It mainly just records the time a deviation is recorded, what area of the lab, what happened, corrective action, and future flow. Overall, I would say it comes down the culture of your lab. Who takes responsibility, and who places blame? If it's a workflow adjustment or something that takes less than 5 minutes to explain, or doesn't affect a patient in any way, emphasize communication between techs and talking to individuals directly to fix process kinks. Doing a whole roundabout where you report it and they find out weeks later about it through a form -- it's a little off-putting and not direct enough for cause and effect adjustment. If it's a real punitive-required situation, that's another problem. Complacency, which seems to be your mention, is something that starts to get into warnings, re-training, responsive action. If someone keeps incorrectly doing a test "their" way, force a re-train (people will want to avoid a whole session of teaching them how to do something they already know how to do, so maybe that's incentive).

Blood Bank abbreviations start to ruin everything

Our blood center could provide units with one or more bags attached. (We did not perform many neonatal transfusions and ordered these for the neonates). The empty bags had labels and our computer was set up for the aliquots. We were fortunate that this only took a few hours. If an urgent need, your process sounds acceptable.

We had to use tube lifters in some of our centrifuges to prevent the tubes from sinking down into the holders. If we didn't use the tube lifters, the cap of the tube would hit the lip of the holder and pop the cap off. Once we used the lifters, we stopped having caps pop off.

We use the Hettich and have separate programs set up so only the wash program has the longer break time included. We also have a site that set two wash programs (one for larger cell suspensions and one for cell button only) allowing only one program to be affected by the increased break time.

I would think that a 4th option in the poll should be: Routinely perform only D typing on babies from D negative mothers. Why do ABO and DAT routinely on these babies?

Oh yes David. I did not mean that individuals who are Partial DVI cannot make anti-D; far from it - they often do when stimulated. What I meant was that the evidence that these individuals can stimulate anti-D in a true D Negative individual is pretty sketchy.

You still need to have all four quadrants of the ISBT 128 blood label. If the 100mm x100mm label does not fit on the aliquot bag (or on an aliquot syringe), you can remove just a portion of the paper backing from the label and let part of the label hang off of the container (or syringe). This is just another option and there is no preferred or recommended option. The label example above is not compliant and it leaves out the two crucial pieces of information required for traceability, which is the DIN and Product Code. Erwin Cabana Technical Manager ICCBBA

We apply the 4x4 horizontally and wrap the bottom part of the sticker around to the other side of the aliquot.

Are you asking about which labels can be placed on the bag and which have to be on the base label?? Some irradiation indicator tags - both Rad-Sure and Rad-Control - have a type of adhesive that can touch the actual bag. Both can go above or below the base label (or at least that is what I have always been told). Most little labels/stickers, like the original Irradiation label in this thread, do not have this type of approved adhesive and are not allowed to be placed directly on the bag. You have to find somewhere to stick it on the base label without covering anything else up.

Question. If the patient is registered, why can't you use the SoftBank emergency issue function prior to the Type and Screen being completed?

Could not agree more.

It was so hard when teaching students not to reach over and flip open that lid. Remember changing broken clips on the immufuges? Or the Dade Cell Washer that added the antiglobulin? I think that is why manufacturers started makng green antiglobulin.

NO! I am a professional blood group sereologist!

It is easier for inventory management if all thawed plasma expires at the same time. When the expiration times stagger, the techs have to be more aware of when a particular product may expire. We have recently had 2 instances where a product expired during a shift and less than 30 minutes later we had an order and could have used the product if we were using the 2359 expiration. With a 2359 expiration, it is less likely that this type of scenarion will happen during the night.

You can use either. For products with an expiration of less than or equal to 72 hours, you must use the exact time. For products with an expiration of more than 72 hours, you can use the number of days @2359 (Technical Manual, 16th ed, pg 219). We have been using the 120 hrs but are in the process of changing to the 5 days @2359.

Thank you, I hope you had a great day of shopping.

An EXCELLENT question Darren ! I look forward to some interesting debate.