txlabguy82

I've actually stepped out of blood bank for the time being and kind of glad - when you have a big bull's eye on your back, because the blood banker doesn't like you makes things very unnerving and I just can't work like that on top of all my other responsibilities in the laboratory.

Ok let me just go through my routine process of pipetting reagent and sample. First of course I label my tubes - there is at least 1 tech that doesn't which no one seems to care about which scares me! Second steps: Pipette 2 drops of patient plasma into the two reverse cell test tube - discard pipette, sometimes I will go ahead and make my cell suspension at this time as well. I always open the bottle of antisera away from the tubes, due to sometimes being dried up stuff on the bottle (I rarely see this being a bad problem, but on a side of caution I never open it over my test tubes). I pipette 1 drop of each anti-sera (all come with droppers) and 1 drop of reverse cell (come with droppers). Reverse cells are always RhD negative I can't remember if that was a question I saw somewhere or it would be pointless in doing a reverse if they weren't negative for the D antigen. Drops are always free-falling as I was taught they should never touch the sides of the test tube or be allowed to run down the side of the test tube to the bottom. When I pipette my cell suspension they are also free-falling never allowed to touch the test tubes. I will be happy if they ever decide to get a ProVue like we've been talking about. We had a similar incident the other day a tech got a negative IS and a +/- at AHG and called the patient Rh - Positive, but apparently nothing was said to him because I definitely wouldn't have called the Rh Positive being a +/-. I've also learned that AABB really are pushing for not doing weak D testing and actually doing genotyping to see if the patient has the genotype(s) that could cause the formation of Anti-D. It just has been frustrating me that depending on who you are influences it being blown up into a big deal or not. I need to see if there are references out there that state how strong of a reaction with Anti-D should one consider a patient Rh Positive at IS or even AHG.

The anti-sera are manufactured in vials by Immucor so we use the vial dropper - we do not put pipettes into the vials that is really asking for cross contamination. All of the reagents have vial droppers - the only thing except of the screen cells since we do these in Gel card, but there was no Antibody Screen ordered initially. The only control was the antisera with the antibody © tube, reagent QC is ran once per day only.

Hi, So this is how I pipette every sample been doing it the same way since I was taught by a very experienced blood banker. I always label my tubes as: A, B, D, C, α, β along with the patient initials on each tube. I always pipette 2 drops of plasma into each of the reverse type tubes first, then I remove the pack cells and make my cell suspension. I then pipette 1 drop of each Anti-Sera into each test tube and then pipette the 1 drop of each reverse cell into each tube as labeled. I then pipette my cells suspension 1 drop into each A, B, D, and C test tubes - then in the centrifuge for 15 secs. Once I read all the tubes I placed the Anti-D and Anti-C directly into the incubator for 15 minutes, washed 4 times, added 2 drops of IgG to each tube and then centrifuged for 15 seconds - read reaction. I've now learned that AABB has changed the standard that Weak D testing no longer needs to be performed and will be bringing this up to my director, as well as, the fact that our procedure doesn't state at what strength a Rh should be considered a reportable Positive. I really hate working blood bank mainly because I have so much on my mind since I am the laboratory supervisor and have tons of projects that need to be done always running through my head.

I am by no means even suggesting it was a cold - was just using it as a reference since you were referring to the moeity being associated with colds at least that is my take. I still haven't heard anyone's opinion on the sample quality issue that I feel could have been the possible associating factor in this case, not saying it was but one has to take this into consideration.

Do you have any information regarding V4-34 moiety you are talking about?

Hi Malcolm, It is a great discussion and I like reading everyone's responses and opinions.... I was also thinking that it could have possibly been a cold, but the individual over our blood bank and my director apparently say there is no way it was a cold. As I was trying to tell her that I've seen cold autos autoadsorp plenty of times at room temp, but they will not listen to anything I have to say. This is the reason I am doing this forum as well as contact some other experts, because them just telling me you made an error in typing and writing me up for it to have the reason to close the event report has me a bit upset at this point.

Hi, not at all. This was actually the only sample I had all evening oddly and I always look at the actual label on each anti-sera vial before I use them for testing, I don't rely on if the reagent is in its correct spot in the rack - never have. I also label my test tubes the same since my clinical rotations.

I do not think the testing temperature really had anything to do with it, because the Anti-A is also a monoclonal blend and it was completely negative, I wondered this too but then researched that the Anti-A we use is monoclonal as well. Also I wonder why they do not state in the package insert that is must warm to room temperature before use, as most any other kit in the laboratory does state.

She was only about 4 weeks I believe, not very far along. I'm trying not to beat myself up, but the individual that oversees blood bank doesn't really care for me and I always feel I have this big target on my back. Of course she also thinks that she knows everything there is to know about blood bank. I also just found out the AABB standard says not to perform weak D testing, so if I didn't do that weak D I would have called it Negative. I wonder why we are still performing weak D testing then, I plan to find out.

We do not use Anti-AB in our facility and I always check the actual label of each vial before using it. I never trust that someone put the reagent vial where it is supposed to go in it's labeled spot. If I followed our SOP as it is written then I did nothing wrong in calling this Rh - Positive. I have never worked anywhere that required special testing for patients that are weak D positive. Yes, I am glad I am getting a lot of feed back with great information. I am still perplexed about the no clots in the sample when I tested it, to several clots in the tube when I was asked told about it 3 days later. My concern is also with specimen quality or some other possible interference of course I am then one being thrown under the bus as I made a definite mistake, because there it is the easiest way to close the event report and move on. I am by no means saying I couldn't ever make mistakes - we are all human.

Could you please further explain what you mean with further testing, what tests exactly?

The observation was macroscopic, if negative/weak we put them right to 37 for 15 minutes, wash 4 times, and IgG added. The package insert doesn't really tell you at what grade you should consider the patient to be Rh Positive. Of course there is an unwritten policy of 2+ or weaker call it negative.

Now that I think about it I want to say I used them cold, which I really never do - but for some reason I used them cold this time. Maybe I was thinking just an ABO/RH and STAT. However, reviewing the package insert doesn't state the reagent should come to room temperature.

Hi All, So I would like to present a scenario that happened to me and get your input. I received a specimen from the ED for ABO/Rh testing on a young female (she had a miscarriage, which at the time I was not aware). We use the BD Pink (EDTA) blood bank tubes for all of our blood bank testing, this particular sample was about a little more than 1/4 of the way full (yes not the best sample, learned my lesson with this case) - there were no visible clots in the tube or in the cell suspension I made for testing (testing was done fairly quickly since it was only an ABO/Rh and we use a STATSpin centrifuge so I had results out within 20mins of it being collected). These were my initial reactions at time of testing: Anti-A: 0 Anti-B: 4+ Anti-D: w1+ D Control: 0 A1 Cells: 4+ B Cells: 0 Du: 3+ Du Control: 0 CCC: 3+ So of course my interpretation was B Positive, which was reported. (We use the monoclonal Anti-D) All of our samples are retested by another technologist if we have no previous history on the patient. The samples sit at room temperature until they are tested and this was one was retested roughly 10 hours after my initial testing, these are the results: Anti-A: 0 Anti-B: 4+ Anti-D: 0 D Control: 0 A1 Cells: 4+ B Cells: 0 Du: 0 CCC: 3+ Du Control: 0 CCC: 3+ Interpretation: B Negative It was tested 2 more times by two other techs later that morning and the report corrected and the patient had to be called back to get Rhogam injection. So of course and event report was initiated at that point for root cause analysis. I was approached 3 days later after knowing nothing about what happened and told that I "miss-typed" a patient sample. After reviewing the work card I of course said No I didn't because I actually remember working on this particular sample due to the fact that the D got stronger at AHG phase. I was extremely puzzled by the results and pulled the sample at this point had been in the refrigerator for 3 days and found that the same had numerous large clots and lots of visible small clots in my cell suspension (however none of the previous techs noted or expressed this to my director). I performed (3 days later) a forward and reverse typing (B Neg), DAT, and IAT. The DAT (IgG and Poly) - Both negative (very sticky microscopically) and IAT in Gel was completely negative. So at this point it was very perplexing as to what happened with the Anti-D. Of course everyone my boss talked to said that this was impossible for the Anti-D to just disappear (I was not inferring that it disappeared to her) and I must have done something wrong, which really aggravates me to use the word "impossible" in medicine. She said it was more logical that I mixed the control tube and the Anti-D tube at the AHG phase when I read the tubes which makes absolutely no sense to me (if the results were reversed from the results I got at immediate spin, then yes that would make sense and I would have questioned the results and started over). OK, so here is my theory as to be the possible cause for this particular scenario has to do with a sub-optimal sample that was in the process of clotting at the time of initial testing - however I can only assume this theory and I know that it didn't interfere with the Anti-A or Control on the forward type, but these are all different antiseras with different blends of antibodies/proteins, etc.. I am thinking that since I didn't see or detect clots when I tested the EDTA sample the first time it is possible that something during the clotting process potentially interfered with the Anti-D causing it to be a false positive. Since the specimen wasn't tested again until 10 hours later when the clotting process was definitely complete there is no way to prove this, unless someone where to have retested it immediately after I performed the first test. We've seen cold autoantibodies disappear after sitting at room temperature due to autoadsorption, who is to say that since the clotting process was complete whatever was causing the interference may have been gone 10 hours later when the full clots formed. My boss refuses to even think this is remotely a possible and I had to have made an error, she said we use to use plain red clotted tubes all the time for blood bank and never had any problems (don't think she is getting that these tubes have no additive and normally the clotting process was a lot faster in plain red tubes with no additive. Then again she also couldn't understand how a clot would get stronger overtime (I wanted to bang my head on the desk with that remark). If I made an error or potentially made an error I would definitely own up to it, but in this instance her suggestion that I switched the test tubes around and reading the control as the patient makes no sense what so ever. Has anyone every encountered anything like this before and what is your thoughts on the potential reason for the various reactions between a 10 hour period? Thanks, -TxLabGuy82