kate murphy

The military does use "walking" donors - other soldiers who have been tested within a time frame, and are available for donation.  Field hospitals are definitely much more sophisticated now than even 10 yrs ago.  Field hospitals do have plasma and platelets as well as red cells available. 
TXA (tranexamic acid) is being used extensively in urban trauma centers.  Recombinant activated FVIIa  (NovoSeven)is less in vogue at the moment due to many bleeding episodes. 
Many of our trauma surgeons are ex-military - or active army reserve - and they are big advocates for simulated whole blood.  Some of our trauma surgeons will be publishing soon on experience with simulated WB being almost as good as WB.  They know nothing is as good as fresh WB, but understand that's an unrealistic goal.
 

In Massachusetts, it's the physicians.
We audit a small percentage of transfusions every month, and consent in one of the things we look for.  We've stopped "letters from the committee" as they are ignored.  We report No Consent directly to Patient Safety/Risk Management.  The hospital lawyers then contact individual MD and their chiefs.  This is also reviewed at Medical Executive meetings.  Very rarely now do we miss a consent.
The higher up the food chain you report, the better the results.

In Massachusetts, it's the physicians.
We audit a small percentage of transfusions every month, and consent in one of the things we look for.  We've stopped "letters from the committee" as they are ignored.  We report No Consent directly to Patient Safety/Risk Management.  The hospital lawyers then contact individual MD and their chiefs.  This is also reviewed at Medical Executive meetings.  Very rarely now do we miss a consent.
The higher up the food chain you report, the better the results.

Clinical management of the patient can be tricky - and sometimes no matter what's done, there's not a good outcome.
We advise following liver function and renal functions.  Much depends on if the potential Ag/Ab reaction causes intravascular hemolysis.  We'd particularly watch LDH and creat.  We may recommend hydration/Lasix to keep those kidneys flushed.  If hemolysis is severe, and LDH is high, we may recommend a red cell exchange.  Which may or may not help.  By the time you're seeing brisk hemolysis, most of the donor cells have been destroyed and there's little to exchange.  Plasma exchange is also an option.
But many times in an ABO mismatch, these things can happen quickly.  The sooner the BB med director knows, the sooner he/she can help guide clinical management.

Clinical management of the patient can be tricky - and sometimes no matter what's done, there's not a good outcome.
We advise following liver function and renal functions.  Much depends on if the potential Ag/Ab reaction causes intravascular hemolysis.  We'd particularly watch LDH and creat.  We may recommend hydration/Lasix to keep those kidneys flushed.  If hemolysis is severe, and LDH is high, we may recommend a red cell exchange.  Which may or may not help.  By the time you're seeing brisk hemolysis, most of the donor cells have been destroyed and there's little to exchange.  Plasma exchange is also an option.
But many times in an ABO mismatch, these things can happen quickly.  The sooner the BB med director knows, the sooner he/she can help guide clinical management.

We do much the same as most, but we prepare in advance.  "Unknown, Patient" with a special ER-#### Medical record # in the lab system to allocate and print tags.  2 O Pos for males, 2 O Negs for females are kept on hand at all times.  
Unknown patients in the ER are banded with a trauma # only until they are identified.  The emergency release form the ER sends to us has this #.  All we need to do is hand write this number on the already printed tags and send to the ER.  30 seconds.  When the patient is identified and we get a real medical record #, we either merge or re-allocate.  Usually we can track/trace all units.
Specimens with only a trauma # are good as long as that the is the identification the ER/OR is using.  When name/MRN changes, we need a new spec.
We do enough emergency issue, that having units tied up tagged is not a problem.  This system works well for us.
We need 2 specs to confirm ABO.  We will issue group O rbc and AB plasma.

Outside of the BB, there is the College of Trauma Surgeons and the Joint Commission.  Both require a policy.

We do 2 folks to id all specs.  Phlebs use bedside scanning/printers.  Phlebs draw about 70%.  We firmly reject all non-signed specs.  No exceptions.  Especially from ED - every hospital I've been in, the ED is notorious for mislabeling, mis-identifying specs.  We're slowly getting bedside scanning/printing to nursing.
L/D and ER are the most common places for WBIT (wrong blood in tube) across the country.  To drop your policy requiring positive id verification because people didn't like it, and then put your phleb staff in the middle is not right.  If you cannot get phleb staff to not use these specs, then I'd suggest another system - bloodloc, typenex, etc.  Safe transfusions begin with the spec.

The entire lab department has an Artel PCS system - same as jayinsat.  Easy, cheap, nice software, good printouts.  Takes us about 1 hour to do all our pipettes annually.  http://www.artel-usa.com/

We do much the same as most, but we prepare in advance.  "Unknown, Patient" with a special ER-#### Medical record # in the lab system to allocate and print tags.  2 O Pos for males, 2 O Negs for females are kept on hand at all times.  
Unknown patients in the ER are banded with a trauma # only until they are identified.  The emergency release form the ER sends to us has this #.  All we need to do is hand write this number on the already printed tags and send to the ER.  30 seconds.  When the patient is identified and we get a real medical record #, we either merge or re-allocate.  Usually we can track/trace all units.
Specimens with only a trauma # are good as long as that the is the identification the ER/OR is using.  When name/MRN changes, we need a new spec.
We do enough emergency issue, that having units tied up tagged is not a problem.  This system works well for us.
We need 2 specs to confirm ABO.  We will issue group O rbc and AB plasma.

We do much the same as most, but we prepare in advance.  "Unknown, Patient" with a special ER-#### Medical record # in the lab system to allocate and print tags.  2 O Pos for males, 2 O Negs for females are kept on hand at all times.  
Unknown patients in the ER are banded with a trauma # only until they are identified.  The emergency release form the ER sends to us has this #.  All we need to do is hand write this number on the already printed tags and send to the ER.  30 seconds.  When the patient is identified and we get a real medical record #, we either merge or re-allocate.  Usually we can track/trace all units.
Specimens with only a trauma # are good as long as that the is the identification the ER/OR is using.  When name/MRN changes, we need a new spec.
We do enough emergency issue, that having units tied up tagged is not a problem.  This system works well for us.
We need 2 specs to confirm ABO.  We will issue group O rbc and AB plasma.

Different photo-reactive chemicals.  Intercept = amatosalen, Mirasol = riboflavin.  Both activated by UV light to cross link DNA/RNA sections to inactivate proliferation of bugs/white cells.  Lots of info with google...

Here's our Clerical Check procedure.  No issues on any inspection, we've been doing EXM for 6 yrs.
SOP II 004 Clerical Checks.docx

Being a generalist with Microbiology experience, here is my take on this: The unit should be reported as positive for bacterial contamination. I would not, though, report the gram stain as "positive" because that is changing the result that the microbiologist reported. They did not see any organisms on the gram stain, so it is negative. If the transfusion reaction workup only allows for a positive or negative result of a gram stain, with no place to report the culture result, then maybe report it as negative with a comment that the culture was positive. 
Ultimately, the culture shows that the unit was most likely contaminated, and that needs to be part of the transfusion reaction workup report. If the report doesn't allow for both the gram stain and culture report, maybe it should be changed to being positive or negative for "bacterial contamination" as opposed to "gram stain" (which, technically, isn't really reported as positive or negative).
 

Different photo-reactive chemicals.  Intercept = amatosalen, Mirasol = riboflavin.  Both activated by UV light to cross link DNA/RNA sections to inactivate proliferation of bugs/white cells.  Lots of info with google...

We use manual gel for AHG crossmatches (not IS).  Our procedure states that the computer will detect ABO incompatibility.  The only time we would add an IS XM is  during computer downtime.  We have not been cited for this.
"Under certain circumstances, a transfusion service may elect to omit the antiglobulin phase of the serologic crossmatch. The antiglobulin test may be omitted if the antibody screen is negative and there is no history of detection of unexpected antibodies. Nevertheless, a procedure to demonstrate ABO incompatibility, either a serologic crossmatch or a validated computer system, is required. The computer crossmatch may not be used if the patient has, or has had, evidence of clinically significant alloantibodies. Typing, screening and crossmatching of neonates can be abbreviated if a specific procedure is available.
TRM.40650

But surely Anna, as most variants of RHD result in us treating them as D-, we are looking at the NEGATIVE, as they can make anti-D if stimulated so to do!!!!!!!!!  Hahahahahahahahah!  

We do 2 folks to id all specs.  Phlebs use bedside scanning/printers.  Phlebs draw about 70%.  We firmly reject all non-signed specs.  No exceptions.  Especially from ED - every hospital I've been in, the ED is notorious for mislabeling, mis-identifying specs.  We're slowly getting bedside scanning/printing to nursing.
L/D and ER are the most common places for WBIT (wrong blood in tube) across the country.  To drop your policy requiring positive id verification because people didn't like it, and then put your phleb staff in the middle is not right.  If you cannot get phleb staff to not use these specs, then I'd suggest another system - bloodloc, typenex, etc.  Safe transfusions begin with the spec.

We do 2 folks to id all specs.  Phlebs use bedside scanning/printers.  Phlebs draw about 70%.  We firmly reject all non-signed specs.  No exceptions.  Especially from ED - every hospital I've been in, the ED is notorious for mislabeling, mis-identifying specs.  We're slowly getting bedside scanning/printing to nursing.
L/D and ER are the most common places for WBIT (wrong blood in tube) across the country.  To drop your policy requiring positive id verification because people didn't like it, and then put your phleb staff in the middle is not right.  If you cannot get phleb staff to not use these specs, then I'd suggest another system - bloodloc, typenex, etc.  Safe transfusions begin with the spec.

We do 2 folks to id all specs.  Phlebs use bedside scanning/printers.  Phlebs draw about 70%.  We firmly reject all non-signed specs.  No exceptions.  Especially from ED - every hospital I've been in, the ED is notorious for mislabeling, mis-identifying specs.  We're slowly getting bedside scanning/printing to nursing.
L/D and ER are the most common places for WBIT (wrong blood in tube) across the country.  To drop your policy requiring positive id verification because people didn't like it, and then put your phleb staff in the middle is not right.  If you cannot get phleb staff to not use these specs, then I'd suggest another system - bloodloc, typenex, etc.  Safe transfusions begin with the spec.

Our phlebotomist are trained to never accept a tube and/or put their ID on it if they did not witness the draw.  If we determine that has happened, there will be discipline for not following policy.  They are very good about ratting out the nurses who try to get them to do that.

We do the same as DPruden - no neg control following package insert.  Your 1st negative patient is your control.  No issues on any inspections for this.

Think over the premise again. What is the purpose of the CAP program (or any other proficiency) ?
Are you testing your facility's ability to get the correct answer (proficiency) or are you qualifying the instruments ?
I would argue that it more important to "test" the operators rather than the instruments and therefore the actual instrument used is irrelevant.
As a sideline.....what would happen if you got different answers with different instruments? That would be a real pickle.

We have a Neo and a Tango.  We run all automated surveys on Neo, and run instrument/instrument/manual/ comparisons quarterly. This has been acceptable to CAP for 10 yrs.

There is no requirement to have medical director or physician sign off.  Any rules in place would be strictly internal policy.  But once it's policy for your facility, you have to follow it.  So it very much depends on the comfort of your pathologist/hematologist in charge.  If he/she is conservative, they will probably want to know.  if he/she is progressive, then not.  Either way, I'd think is should be in a policy/procedure spelled out for your staff.