Ensis01

Great post and exactly my point. Blood bank needs to ensure that our requirements are met but it's a nursing documentation/workflow issue.

A little late on this subject but I thought I would chime in anyway.  We suffered the same problem as you described a few years and 2 employers ago.  When trying to determine what to do about it we discovered that the nurses were being "required" to document the same information in multiple places.  This made no sense so I worked with a team from the nursing department and we came up with a system that only required the documentation in a single place and did away with the other locations.  An example is that they were being required to document vitals both in the patient's chart and on the transfusion record.  Obviously they were much more in tuned to documenting this info on the chart so we removed it from the transfusion record.  Any inspector who wanted to see the info was shown the chart.  Over the years I have discovered that simplifying a process usually enhanced it.  

If the information is required, then it is required.
If the nurses can't be bothered to fill it in, go down the disciplinary route.
If the information is NOT required, then ditch that bit of the form.

Dr. Pepper, it's no wonder you're a blood banker!  Search for the answer and never give up until you've found it.  Bravo!

That's what I was getting at.....but then, I got curious, and looked it up to see if it was actually true about water draining one way or the other. It turns out that in a perfect, static state of affairs, Coriolus forces can indeed cause the hemispheric effect, BUT in the real world those forces are vastly weaker than other influences at play and are overcome by variations in the shape and structure of drains and tubs, motion of the water in a basin caused by use or a slightly off center (which they all are) faucet filling it up, and so on. Hence it joins a long list of charming but untrue urban legends. There's an equatorial nation where, for a modest fee, you can see a toilet on the north side of the line flush in one direction and one on the south side flush the other. They're rigged.

We hired one last week for 3rd shift.

Same reason I do not store my Guinness over my toilet...
 
Scott

On our previous computer system we had the option to write in the lot number and expiration date of the antisera when we were antigen typing. But it was really cumbersome and time consuming. It was also hard to tell if someone had done QC on a particular antisera for the day and if we didn't know we would have to repeat it. So, we went back to writing on paper and it seemed to work better for us. We can flip open the book and tell at a glance if we need to do QC on JkB antisera no matter what shift you are working. The computer is a great aid but not always the best answer.
 
 

Bear in mind also:
if testing was performed without documented QC, and that testing was used as pretransfusion/compatibility testing for a unit of blood that was issued from your department, it requires a mandatory report to the FDA as a biological product deviation.

Recording it is part of the process.  One of our accrediting agencies (the MHRA) say that, if it is not signed, it wasn't done, and if it is not signed AND dated, it is graffiti.  Whereas, I think that they go well over the top a lot of the time (and few have the guts to challenge them), I happen to think that they are right about this (and it hurts me to say so, believe me)!!!!!!!!!!!!!

If you have doubts about there performing (or not performing) qc what is to keep them from still not performing it if you use paper vs electronics?  Some computer systems can be set up so that if QC is not performed at defined intervals you cannot generate results . . .
If you are serious about them not performing but just entering results:  a) you'd have to prove it somehow; b - you'd have to file biologic product deviations everytime you transfused a product that was done with circumspect QC; c) - discuss with your HR folks, might have to terminate at least one to send a message.
I had a student once that did not do qc, unfortunately for her I had replaced her reagents with food colored saline.  My staff saw her dereliction, though she continued to deny . . . even though she did A work, I wanted to fail her but her coordinator convinced me to just give her the minimal passing grade.
GOOD LUCK with this one!

Our previous blood center used to send us RBC units with antibodies when things were tight, usually around holidays. They asked us before they sent them and we had to OK it. We did not antigen type the patient prior to giving to the patient. The amount of plasma is generally very low and even if the person was positive for the antigen, it shouldn't cause much problem.  We tried very hard not to give to "frequent fliers." We tried to give to patients that were about to be discharged and probably wouldn't be back, e.g. ortho patients. We would also make a note in a comment box that a RBC with "XX" antibody was given on XX date. We could also put in a comment that is attached to the unit when we brought it into inventory.
It can get confusing if you give a unit with an antibody to a patient and then that patient hangs around long enough to need a second crossmatch. It can appear that the patient receiving one of these units has developed an antibody. Then the question becomes "Is this the passive antibody from the unit we gave 3 days ago or is this person building their own antibody?" This didn't happen often since we issued these units to people on the way out of the door if at all possible.

We've been converting FFP to TP directly for some time now.  All of our thawed units start with a 5-day outdate.
 
Scott

Yes, if you are AABB accredited, then you must do an ABO determination (as defined in 5.14.1) on the initial blood sample and an ABO determination (as defined in 5.14.1) on the 'retype specimen'.  FDA, CAP and other accrediting agencies do not prescribe how the 'retype' must be done.

At least get rid of the "to 45 degree C" part!
Scott

I've only washed with warm saline when the patient has a strong cold agglutinin.

I agree that you would use the first sample for subsequent transfusions until the sample expires.  Your point that the person may have an unexpected antibody prior to the first transfusion that then explodes with a second unit could happen. If the patient does have a transfusion reaction because an unexpected antibody was present that could not be detected with the first antibody screen, it could result in a delayed reaction (>24 hours but less than 28 days after transfusion).  It generally wouldn't be an immediate hemolytic...unless the wrong blood type is transfused.      If the patient did have an unexpected, undetectable antibody and had a reaction; your transfusion reaction work up would discover this and moving forward, your transfusion service would have information to give antigen negative blood.  As blood bankers we want to give the best product all the time.  Following the rules/processes/procedures will help us stay on that course. 

Perform Crossmatch using existing T&S sample.   The sample is valid and there is not enough time to develop an antibody .
 

It depends on how their policy is written and how stringent the nursing reviewers are - if they documented issues with an IV (or something else legit), I wouldn't nick them for that. I would, however, make sure the infusion was complete in 4 hours.

If I remember correctly, our policy was very similar to Mollyredone's.  They kept the unit on the floor and transfused it up to the end of the 4 hour time limit from issue.  No reason to bring it back and then reissue.  Quarterly I reviewed every transfusion occurring during the month and one of the things I looked for was issue to completion times.  Granted, if this did not occur during the month I reviewed it would not be caught if the 4 hours were exceeded but at some point you need to have a little faith that other people actually attempt to follow policies and they were reminded of the 4 hour limit during the discussion of what to do with the unit initially.

We don't take the unit back.  If they call us because the unit has been issued and the IV is not working, we ask if they can transfuse it within 4 hours of issue.  We make them keep it with them.  If they can't get it transfused within 4 hours we would discard it.

Here in the US, according to the FDA CFR640.2c3, we cannot issue a unit that has not been maintained at required temperatures ... we can take it back, but we cannot issue it.  Therefore, I believe it is a violation of this requirement to hold the unit in the BB and reissue it, even if it is for the same patient, even if it is within that 4 hour window.  BTW: The 4 hour limit is for the completion of the transfusion, not the start of it.
 
In addition, the FDA has told us during our most recent inspection that the CDC determined that once issued blood is delivered to the location, it is considered 'in storage', not 'in transport', therefore the 1-6oC temperature restriction applies.
 
Given those restrictions, when an attempt is made to return blood to us and the unit temperature is greater than 6oC, we tell the infusionist to keep it and try to get the transfusion completed within 4 hours of the issue time or we will take it but will have to discard the unit.  They usually opt to keep it ... and they usually get the transfusion accomplished in time.
 
I see no value to re-entering the unit then reissuing it other than to create busy work for everyone, set yourself up for a citation (if you are in the US), and create confusion. 

In my opinion, this very much depends upon the underlying pathology.  For example, if the patient has an auto-immune haemolytic anaemia, the chances are very strong that the DAT will be positive before as well as after the transfusion, and that any eluate will be positive with all red cells tested (of normal type).  The chances of detecting a new antibody specificity on the DAT positive red cells under these circumstances is disappearingly small.
Therefore, if the sample is sent to a reference laboratory on a regular basis, your manager will be 1) showing a degree of ignorance that should be surprising, 2) will be upsetting the staff of the reference laboratory, as most have enough to do, without having to perform extra, unnecessary work, and 3) as you are in the UK, will be wasting the tax payer's money (and, as a UK tax payer, I feel very strongly about this).
If, on the other hand, the positive DAT is new, then a reference laboratory would be delighted to help out.
Of course, what your manager could do is to buy his/her own laboratory an elution kit, and train his/her staff to use it!!!!!!!!!!!!!!!!  This may bring the cost of the kits to meaningful results ratio to the overall pathology manager, which could be of interest!

..............And how do you know if the pager breaks down at the same time as the remote monitor breaks down at the same time as the fridge breaks down!!!!!!!!!!!!!!!  Eventually, you have to trust a system, or send the inspector to the psychiatrist for assessment!

Isn't everyone overthinking this? Weak reverse groups are not uncommon and it's a lot of effort to go to for a naturally occuring and totally normal phenomenon. Is the patient aged, immunosuppressed or on chemo?