David Saikin

I have found that it does not hurt to inform the MD of an ab history . . . not that a great many seem to understand the implications HOWEVER when it hits the fan, as it occasionally does, I at least have the documentation that someone should have known this information. Actually, at my instituion it would be a moot point as we would automatically set up ag negative, ahgxm compatible rbcs routinely for any in pt or preop pt.

I put a comment attached to the negative antibody screen: "previously identified anti-*** not demonstrable at this time."

We report the unit number, symptoms and the pathologist's interpretation

Don't worry Brenda
It's really not difficult - and it gives you the feeling you've gone back in time and are doing 'real' lab work rather than pushing a button.  And SOOOOO nice when you get a positive (well, not for the patient, though).

Except that the Transfusion Checklist has a separate item about rare antisera. The question is - do expired panel cells fall under that checklist question? We once got cited for not having a policy defining rare antisera. So we wrote one that defined it and included expired panel cells for rule outs in that procedure. Our last CAP inspector said we were fine for that.
 
I would think that the area specific checklist trumps the all common checklist if there's a discrepancy between checklist questions.

In my experience, reactions with anti-A,B tend to be stronger than with anti-A or anti-A1, even in this era of monoclonal grouping reagents.

I agree with Malcolm in that almost all weak A or B antigens will react better with anti-AB than with anti-A or B alone.  monoclonal anti-AB reagents should be true anti-A,B rather than a mixture of anti-A and anti-B.  The latter are not really worth using.  This could either be a true weak sub type of A; or, as your patient has a leukaemia, it could be the disease that is weakening the antigen. 

I like this topic:  THE WEIRDESTTHINGS I WAS EVER CITED FOR
 
For me that was not having my facility ID on my ab panel sheets.  I knew I was in for it when the inspector started off saying she knew she'd have to dig to find something "in Dave's lab!"  This was in the day when the inspector sent the report to the AABB Area Chair and he/she decided what was actually citable.  I called my area chair and told him  1. that I couldn't believe he cited me for this and 2. I wanted to inspect his blood bank (aganist the rules). 

I am just like you Mabel

The two weirdest things I was ever cited for:
 
Not logging the expiration date of non-sterile gauze (I had no idea such a thing even expired...)
 
Inspector found 1 balance tube in the entire lab that was expired.  We were cited that it was expired and it did not say the words "BALANCE TUBE ONLY" on it.

A nice idea but I think that there are too many variables in inspections, whether AABB or CAP. 
 
First off, the AABB assessment is pretty subjective and is based not only on the assessor's training but also on their experience, their bias (yes), and their interpretation of the standards.  You would end up writing a long dissertation about why your received non-conformances, your agreement/disagreement with the report, how you justified what you felt shouldn't have been cited, AABB's response, etc., etc.  I know when I did assessments (retired from I&A last year), I looked primarily at the Quality Plan and its implementation and usefulness.  Yes, I still looked at reagents, spoke with the techs, and verified mandated policies/procedures but . . . when i received the packet for an assessment I get to see what the previous event had reported.  Some folks are into the minutiae (which I found to be a major waste of time/effort). 
 
Second:  CAP has a checklist - yes or no.  There are many shades to yes and no and a great many inspectors can't see the forest for the trees, and some have limited Blood Bank experience.  Granted, the CAP is also educational for both parties, but I have found that a great deal of effort is wasted on back and forth with CAP on issues which the on-site inspectors did not/would not understand.  While my BB has always had minimal non-confomances, the entire lab has usually had 60-75% of the cited non-conformances removed by CAP central.  Are you going to document all the back and forth, your opinion of the inspection team/your inspector, how your responded?  Seems like a lot of time spent.
 
Or are you just going to say my inspection was great (and why), good (and why), sucked (and why).  I think you can do this under the ACCREDTATION forum by making a comment or asking a specific question about a standard. 
 
Oh and let's nor forget the FDA!

Surely, SMILLER, it must be as the blood enters the vein, as before that, there is no transfusion?
From avowed Red Cell Serologist, rather than a Blood Transfusionist!

The reason that Jk(a) variants tend to weaken the antigen expression is because of the way the amino acid residue that produces the antigen is very close to the red cell membrane and is"semi-hidden" by the third external loop (see the attached diagram).Kidd Molecule.ppt

Why don't you just validate the antisera for use with gel.  You can use the buffered gel tubes and only 25uL of antisera (or 50 if you want to).  You just have to validate that the antisera work in gel (they do) and have a good procedure.   
 
If you want to turn gel cells into 3% cell suspensions you will need at least 5 drops washed to a dry button and resuspended in saline (or whatever you use).  Ortho says 4 drops but I find the button too small and do not do this at all.
 
You can extend the life of the antisera to your comfort level as long as the qc works (theoretically).  CAP and the FDA say you can do this so you can

It was pretty obvious but - I've been in the field over 40 yrs and this is the first anti-f for me.  It just made me uncomfortable but when I wrote out CDe/CDe instead of R1R1 I thought for sure that it could be anti-f.  Just needed some reassurance.

I use manual gel and tubes as back up.  I use an ab positive CAP specimen for my comparison so I do 3 a year.  I document reactivity of the cells, whether they are screening cells or ABORH types.  I state in my protocol that I expect pretty equivalent results from the ABORh testing and that with the  antibody testing it is anticipated that gel will display stronger reactions than PeG or Liss.

I have ABSOLUTELY no doubt that the antibody is anti-f.
Just because the patient is e+ in no way precludes him from making anti-f, the "other name" for which is anti-ce. In other words, it is a COMPOUND antibody that will only react when the RHc and RHe genes are in the cis position (but not in the trans position, and not when only one of the antigens (in this case, the e antigen) is expressed on the red cells of the antibody producer.

Thanks Malcolm - I was leaning there.  In fact I just called the hospital and told I was pretty certain it was anti-f.

Anyplace I have ever worked, we checked records on all samples submitted to blood bank.

Silly question, but rather than getting dinged at inspection at worst or doing a lot of unnecesasary testing at best, has anyone actually asked CAP??

Ultimately, it's the responsibility of the ordering physician to request the appropriate component. It is fine for us to be a backup, with problem patient files and computer warnings that a patient may have special needs, and hospital transfusion policies listing "standard order" indications for certain components, and to question odd requests. I don't think we should be the first line of defense, however. If your lab has the resources and backing (like a stable of 24/7 knowledgeable pathologists) to dig deeply into every blood request prospectively and ensure that the component is totally appropriate for the patient, you are blessed. I don't think that describes a lot of us, though.

Just doing my job as devil's advocate.  Suppose the patient comes in for a diagnosis unrelated to the reason they may need irradiated blood products.  You would never know.  I've mentioned in the past that I can  play the "what if" game with the best of them.  I think Terri's approach is the best you can hope for but realize that you can never cover every possiblity.  With out a policy such as she describes I have never felt that laboratory staff should be modifying orders on their own. 

We have a policy for what our indications for giving irradiated products are.  It is a joint policy with the Medical Staff and is approved at the Medical Executive Committee, so the physicians are agreeing that this is our policy.  That way we are not placing an order, we are following policy as a standard of care.  This works the same as our reflex policy, which is also approved at Med Exec so that we can automatically order an ABID for every positive antibody screen without having to get a doctor's order each time.
 
So if a physician orders irradiated for a new patient or if we see a new patient that qualifies, we look at their diagnosis and if indicated, we add irradiated as a requirement.  If the physician's specific order for it seems unwarranted (non-cancer patient, sickle cell, etc) we will call and question.

In general I would say that any dept in a hospital cannot create an order without a specific physician's request, and that includes BB products.  Not sure but I think there are regs covering this.
 
Here, if suspicious, we would question an order and ask the ordering location to check the order and then order something else if needed.  I would say that it is not appropriate for a tech to decide what diagnostically does or does not require a particular product, beyond making sure that there is proper documentation (like an H/H result for issuing RBCs say).
 
If we have a history of say, irradiated products being used, and a regular unit is ordered, we would alert the floor to the discrepancy and ask them to check with the physician.  People do stop taking chemo or whatever and can go back to regular products. 
Scott

Thanks - I give Rh phenotype specific if possible . . .