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PERHAPS weak D was included because a positive weak D would alert you to a possible false positive fetal screen.

We just finished with our JCAHO inspection Oct 2018 and nothing was said about how we handled Rhogam. Our pharmacy orders the Rhogam inventory since Rhogam is given in the MAR (has a NDC #) and pharmacy gets the revenue when administered. Blood Bank stores the Rhogam and determines who is a candidate. Blood Bank calls the pharmacy when we need them to order more inventory.

Where are you located? Our Immucor rep supplied us with a coding guide for reimbursement, and you can also send specimens directly to Immucor for testing. We send ours through our Red Cross IRL. At this time, the last information I received is that reimbursement is for a complete HEA Genotype only, Rh genotype for weak/ partial D is NOT reimbursed because only the complete genotype is FDA approved. I reached out to our Immucor rep for more information if you are interested.

We had our Rhophylac stored in Pharmacy as we thought this was a JCAHO requirement. We had nothing but problems. The OB floor would bypass us and call the pharmacy for Rhophylac along with the ED department. It was causing havoc for us. After 3 years when a new pharmacy director came along we finally got our Rhophylac back in the blood bank. We just had AABB and JCAHO inspections and nothing was said about us stocking Rhophylac in our department.

I posed the question to JCAHO online and this is their response: No, this is not a mandatory practice. Rho Immune Globulin is a "blood derivative". Our practice is to survey blood derivatives (albumin, Rhogam, factor concentrates, etc.) under either the Immunohematology or Medication Management standards, depending on which of the two hospital departments is overseeing it. Specifically, if managed by the blood bank, we would survey it under our Immunohematology standards in the laboratory manual. If managed by pharmacy, we would survey it under the Medication Management standards in the hospital manual . The former has stringent tracking requirements (see QSA.05.01.01 and AABB standards 5.1.6.1 & 6.2.3) ; the latter requires sufficient tracking to determine who may be impacted in the event of a recall (MM.05.01.17). Note that full compliance with the intent of the standards can only be assessed during an onsite survey. Please feel free to contact me directly with any further questions or discussion for clarification purposes.Megan SawchukJoint Commission