Ensis01

The front and back label bar codes are identical.  It maybe that when you bring the unit into your LIS system the double zeros and check digit at the end of the unit number are not used but when the vision scans the label for ABO conformation they are, thereby creating this discrepancy. 

What I was trying to get at is if the DAT is negative and the antibody screen is negative why would anyone consider it necessary to provide D negative red cells.   Another thought/question just occurred to me (odd, I know), why are they transfusing the baby?  Is it due to excessive blood draws or is the a hemolytic process going on?  That would make a difference as well.

If you incorporate the main exceptions to policy into your SOP; it gives techs a clear path to follow if / when time is short or it is 3am. As you indicated it is hard to get O neg little c neg units (fresh or frozen).

I would be interested in knowing how many antenatal RHIG doses the mother received. While it is possible for RHIG to cross the placenta and cause HDFN, seems to be extremely rare. The probability increases with each antenatal dose. That said, I agree with you that the baby's own cells should have sequestered any residual RHIG in circulation though I probably would not change my policy. I would just document the deviations when necessary.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4877609/

Yes John,  With higher dose anti-D immunoglobulin, the DAT of a D Positive baby is quite often positive.  In the UK it is now quite common to give a dose of 1, 500 IU of anti-D immunoglobulin at 28 weeks of gestation and, as a result, many babies have a positive DAT, but I have never heard of clinically significant HDFN as a result,  Physiological jaundice is also quite common in newborns, whether the mother was given anti-D immunoglobulin or not, and whether the baby is D Positive or D Negative.

If there is detectable anti-D in the antibody screen, would usually transfuse Rh negative blood, although the risk of clinically significant hemolysis is low.  We do not know that mild hemolysis is benign, for one thing.  
As for "freshness" this turns out to be one of the things we got totally wrong. Fresher blood (<7 days say) is probably less safe for reasons unknown than blood stored 7-21 days.  Fresher blood is associated with increased infections in the recipient in randomized trials, so our approach to this in our center has turned 180 degrees. We prefer not to use <7 day old red cells, but define fresh as 7-21 days.  Randomized trial data. 
Thus in your situation I would strongly prefer 7-21 day old Rh negative red cells to giving <7 or <5 or whatever Rh positive red cells to a child with anti-D from Rh IgG.  Freshness is harmful nonsense with a long history of expert opinion that, regrettably has been proven wrong by data.

My Medical director wanted/authorized Rh pos to all during massive transfusion protocols. That made a huge difference in conserving Rh neg and especially Oneg. 

Bottom line is believe the lab test results (data) and make clinical decisions weighing the risks and benefits :).  A patient who has anti-K (mimicking, auto, passive, or otherwise) should receive K negative red cells.

The observation that antigen negative cells can yield an eluate with an antibody for an antigen not present has been known for more than half a century I believe.  It's often referred to as the Matuhasi-Ogata phenomenon, first reported in the 1950s and 1960s.  My mentor, Joe Bove and Patrick Mollison wrote about this a bit later in the 1970s based upon work Bove did during a sabbatical in London. Needless to say, I heard about this often as a resident physician under Bove's supervision :).  Brings back memories....
Immunology,1973,25,793.
Non-specificBindingofIgGtoAntibody-coated RedCells (The'Matuhasi-OgataPhenomenon')
J.R.BOVE,*A.M.HOLBURNANDP.L.MOLLISON
MRCExperimentalHaematologyUnit, StMary'sHospitalMedicalSchool,LondonW21PG  Summary.Severalobservershavereportedthatredcellscoatedwithaspecific blood-groupantibodymaytakeupasecondblood-groupantibodynon-specifically, aneffectknownasthe'Matuhasi-Ogataphenomenon'.Inthepresentwork, thiseffectwasinvestigatedusingeither'25I-labelledantibodiesofvarious specificitiesora1311-labelledpreparationofIgGlackingrelevantantibodies.In confirmationofmuchpreviouswork,itwasfoundthatredcellstookupappreciableamountsofIgGnon-specifically;however,thisuptakewasnotincreased bypreviouscoatingoftheredcellswithspecificantibody.WhentheIgGtakenup non-specificallyincludedablood-groupantibodyinrelativelyhighconcentration, aneluatesubsequentlypreparedfromtheredcellscontainedsufficientoftheantibodytobedetectable.Thus,thefindingofunexpectedantibodiesineluatesmay beduetonon-specificuptakeofIgGratherthantoadherenceofantibodiesto antigen-antibodycomplexes.

Thanks for the reply @Malcolm Needs!  Makes me feel a little better that something has "out-foxed" us all....including you!! 

Well, the simple answer is "YES", but whether you believe me or not is up to you.
When I was the Reference Service Manager of the Red Cell Immunohaematology (RCI) Laboratory at the Tooting Centre of the National Health Service Blood and Transplant (NHSBT), we had a patient's sample referred to us from one of our samples from the East Coast of England (I have to be careful not to identify either the patient or the hospital) who had an anti-K, having never been transfused with K+ blood.  However, this patient consistently had a positive anti-K in their plasma, and also, believe it or not, could have anti-K eluted from their erythrocytes,

Knowing the situation (i.e. we had not supplied K Positive blood to the hospital for this patient for many years, AND knowing that they knew what they were doing - they would NOT have given K Positive blood), I was wondering if either I, and/or my staff (in their case, almost impossible, even if I was fallible) and so we sent the sample to the International Blood Group Reference Laboratory (IBGRL) for confirmation.  The report we got back (from Joyce Poole) was that they also detected an anti-K, from an apparently K Negative patient with a positive DAT, but the eluate was (again, apparently) anti-K!

Unfortunately, we lost track of this patient, BUT, if Joyce was a bit foxed by this case, I feel TOTALLY free to be foxed as well!  Her theory was that this was a case of a "mimic-anti-K", rather in the same way of almost all WAIHA specificities being a mimicking "specific Rh antibody".  Since then, of course, it has been shown that low prevalence antigens within the Kell Blood Group System can lead to "strange" antibody specificities within the Kell Blood Group System, together with weakly expressed antigens within the Kell Blood Group System.

I am NOT saying this is a total answer to your query (but it is the best I CAN DO!).

I've experienced remote alarms that were monitored by facilities crew.  Even though the lab was 24/7.  Facilities even did the alarm checks.  Seemed to work pretty well though I had to tweak that system while I was their temp manager.  Alarm probe in freezer in the air - they wanted it to be sensitive, well it was.  The chart looked like a supernova explosion.  I told the medical director if I was inspecting they would be tossing everything out.  Once we put the probe in 50% glycerol the system worked pretty well.  I still did weekly checks on the documented temps for both refriges and freezer.  Otherwise, I agree, if you are 24/7 there is no need for a remote alarm.

Most certainly it can.
There have been published papers on newborn babies being typed as D Negative, and K Negative, not because they have received an IUT, but because their mother's antibody has such a high titre that they sensitise virtually every antigen site on the cord red cells, thus causing a sort of prozone effect.

The same can happen with a "blocking antibody" and AHG.

It is also not uncommon for newborn babies with ABO HDFN to have a negative DAT, and be released from hospital, only to be brought in again when they become "floppy", and for the DAT to then be positive.

I've seen it a couple of times. Both were patients with WAIHA who were very actively hemolyzing their own red cells. DATs were 4+++ - like almost didn't need to centrifuge - positive.  Sent both samples to reference lab and neither one could be resolved. I think they tried 12 washes on one sample without success (more than policy, but they were curious to see what would happen). Ugly cases, idiopathic as far as the experts could determine.

Agree with Cliff.
The alarm at the nurse's station would, I believe, be considered as a 3rd party under CAP as it is outside the lab's direct control. Years ago, before we had 24 hr staffing in the lab, we had a similar set up with the alarm in the telephone operator's booth. That position was staffed 24 hrs. The problem was that the operator didn't always respond to an alarm or didn't respond in a timely manner. During a CAP inspection the alarm was triggered in the blood storage refrig and the operator didn't respond. It was day shift and when asked, she said she didn't call because she assumed someone in the lab would respond to it. We were cited because we couldn't demonstrate adequate alarm response.  If you are using nurses to respond, you could face a similar citation if they don't follow through with notification.
 

If this is the case, I would propose you do not need remote monitoring.

So, why, pray tell, does the alarm even sound at a nursing desk?  This is quite unnecessary and obviously inconvenient for all involved.  If the reason is, as usual, "that's the way be been as long as anyone remembers", it's time for a change.  Hopefully you can get this easily rectified.  Good luck.

I'm curious on what you consider a 3rd party outside the lab.  The engineering department within the hospital could be considered a 3rd party out side the lab but I personally would consider them acceptable because they could react immediately to the alarms.  If you are referring to someone far outside the facility that would be considered a subcontractor I would be hesitant to consider this acceptable but that's just my opinion.

@Okie, we started doing the whole panel (on the eluate only, not the last wash) because we had an elution CAP survey that had a Di(a) in it. The screen cells, of course, did not pick it up. It was an ungraded challenge but we decided in the long run to perform a full panel on the eluates in case an antibody against a low frequency antigen is causing the positive DAT.
@AuntiS, I'm curious, why are you running Acells and B cells on the last wash? I understand the eluate but I do not see why you would need to ever run more than the screen cells on the last wash.

In this paper from 1985, "The Lui elution technique A simple and efficient method for eluting ABO antibodies c. s. FENG, K. c. KIRKLEY, c. A. EICHER, AND D. s. DE JONGH, TRANSFUSION 1985; 25:433-434.", the authors thank A. Lui. MT(ASCP)SBB, who introduced this technique to them. Therefore, I believe Lui is the name of the MT who invented this elution method. 

We do a screen and, if indicated, A and B cells.
sandra

Sounds like I will prefer a good quality, fast black and white

I just answered this question.

My Score PASS  

Years ago, we kept the segment used for the crossmatch in a covered tube rubber banded to the patient’s specimen.  When we went to the electronic issue, we switched to pulling an extra segment when we received units.  It was bulky keeping the segs with the patient specimens. Plus, we did a lot of add on crossmatches and had to keep all the specimens organized and spaced in case we needed to rubber band more segments to the tube.  It was about 600 beds with a busy OR. In the decades we kept the crossmatched segments, we never found one time where a crossmatched segment did not match a segment from a unit involved in a transfusion reaction.  When we started pulling and keeping an extra segment on receipt, I thought we might miss keeping some segments, but we never had a problem finding a seg for a work-up.  Our specimen refrigerator looked a lot neater and specimens took up less room. You could check your reaction work-ups to see if there has ever been an error found when doing the reaction work-up. If not, you could demonstrate the extra time and supplies involved in keeping the crossmatched segments was not justified. .  

Agree with @donellda. Running the antibody screen on the last wash is all that is necessary. It will show that there is no reactivity verifying adequate washing for the elution procedure, which is why you are testing the last wash.