Eoin

Sorry Winter, Maybe I am getting old & silly - is your question relating to testing the monitoring devices; blood product; or of reagents/ gel cards. If you can be more specific I should be able to help you. Cheers Eoin

Have enjoyed your posts, but an official welcome comes from me as well. Look forward to hearing from you in the future. Cheers Eoin

I echo Liz's comments. Fantastic job- fantastic international forum (or will that be Fora now)? Well done Cheers Eoin

Hi Generic, You will not go too far wrong reading and participating in this community of learned women and men. I am at it a tad over 40 years now and still learning. They will need to ***** the lid on tight to stop me. (Just thought, that will be another experience!) Good luck with your career. Mind you, I remember reading a quote "Luck is a funny thing, the harder you work, the luckier you get". Who said that? Was it Trueman? Cheers Eoin

In answer to the question about re-design of the lab, BB should always be segregated and placed into the quietest corner. The no interruptions rule when crossmatching takes a lot of follow-up frequentl. If you have one lab quality meeting for the whole place you are in clover. If you have your own for BB, it doesn't hurt re-iterating the motto there wither and you can always send a written request to other departments to be diseminated to all staff. They all understand and respect it BUT do make it written - if it isn't written, it didn't happen. Cheers Eoin

As a Quality Manager, I concur - zero tolerance. You can use a table - error types across the top, tech names down the side. If there is a vertical line on errors of one particular type (i.e. by a number of techs), you have a process fault issue. If there is a horizontal line against one tech, you have a tech problem. Easy to use and follow. I applaud all "No Blame cultures", but remind peorple it is also a "Just Culture" - you won't be disciplined for an unaccustomed lapse, but you are also responsible for your practice, so more than one will be a cause for concern (re-training and recompetency testing for a start). We have a full SOP for disciplinary procedures - Verbal warning, written cause for concern. A second written cause for concern is time for management action on the issue. I agree though that at all costs a RCA needs to be done on all non-conforming work, otherwise you will never get to the bottom of this. Do you have a Quality Manager in your lab? If so, maybe he/she needs to go. This should have been sorted before 10 occurences EVER, not in just a 12 month period. Good Luck, Eoin

I should have replied with the question. Can't even find it in the thread now - you guys have far too much time to be doing posts, but it was something to do with the duffy system ?????? I thought the answer was to do with Duffy negative africans who carry a silent Fy-b allele with T to C substitution at 46. This has apparently evolved twice in black africans, and an apparent evolution of this phenotype occurs in Papua New Guinea. (Sorry I can't find the question). Maybe it's like the three elderly gentlemen walking along in England. The first one says "I say, is that Wembly?" The second replies "No, it's Thursday" and the third one says "Yes, Iam rather, let's pop in here for a drink". See, I'm even confused myself. Happens when you take a day or two off. Cheers, Eoin.

Good luck anyway. Remember - lots of citations may bring more resources. Cheers Eoin

Is this the mutation that is only in Papua New Guinea? You have me intrigued now. Mr Duffy, in whom it was discovered would be chuffed to think that we are still debating what was originally described in him. Cheers Eoin

Wow, some problem. Have inspected in the past - pick an employee, have the manual on my knee and ask - how do you do (say an auto-absorption). If it disagrees with what is in the manual, it would be cited. Also need evidence of regular updates and quality improvement and evidence that all staff have signed off on methods as having read them. I remember the steep hill of when regulation came in years ago - daunting, but when done, is easy to maintain. Good luck with it all. Cheers, Eoin

Hi Folks, I think it is bad to jump immediately to conclusions. A lot of assumptions may have been made here. I agree with Marilyn, talk to the person. I would like to know the circumstances (overworked, insufficiently trained, etc, etc). Was there a second checker, or was it on-call. If we sacked all techs who had made a mistake in any areas of a lab (before you think it, yes, I know this is different as it is a serious error), the labs would be pretty lonely places. I am more wary of an employee who would tell me they have not made a mistake (or of those who would attempt to cover them up). I also agree with Marilyn, that if this person has sound, logical reasoning, they will have learnt from this mistake and are unlikely to make a similarly serious error in the future. If this is not the case, simple observations of their working habits will soon demonstrate if they do not think in a systematic, logical progression for a given process. Try them on a simple double antibody mixture ident. Who checked the references on hiring? Maybe they were told he/she was agreat worker, but for this single abherrent issue. Lots of privacy issues here to be wary of too. Good Luck. Cheers, Eoin

Have seen clinical notes of "Filthy Babe" on a request. On checking paediatrician's notes we found that it really said "Fitting Babe". Maybe the nurse thought we might come up and wash it? Jack of all trades our lab. Cheers Eoin

Welcome, A problem shared is a problem halved. Lovely to hear of triumphs as well - share SOPs or forms, unusual cases etc. You will get great joy from this site. Cheers Eoin:cool:

My Vote - Yes to Gel (or more correctly column agglutination technique - because it is not strictly a gel {you can tell we were picked up at regulatory audit for that recently :mad: and had to change the wording in our scope of practice - but we still call it gel in the lab}), No to Manual with microscopy for DAT. Cheers Eoin:cool:

Suspect Temp Rises are 1.5oC above the surrent baseline temperature. Regards, Eoin

Hi, We run our Non-Conformance System as a "No-Blame" culture, but staff hate non-conformance letters or being recalled for re-education / re-competency testing, and despite many newsletters etc about the no-blame, we still get adverse comments in our user surveys. After all, they are accountable for thier practice. I read an article recently in an ASQ publication about a "Just Culture" which refers to three types of behavior - Human Error - inadvertent action - a mistake At-Risk Behavior - a choice that increases risk because it is not recognised (or outside SOP) Reckless Behavior - a choice to consiously disregard a risk that is substantial and unjustifiable. I think "Just Culture" may be a more acceptable approach, even though it is essentially the same described in a "Just" manner. The non-conformances often identify process weaknesses and leads to improvement. If an adverse event happens it is not good, but it is unforgivable if the institution does not learn from it and put in better process descriptions. Your hospital has done a good job in re-defining the process. Often things are not spelled completely out because they have not occured. Well done Deny Cheers Eoin

Welcome, Enjoy and post away Cheers Eoin

Welcome, we look forward to your posts Cheers Eoin

Welcome. Even to us oldies, this is often used as avaluable resource. I am 40 years in BB now and still learning (maybe I'm just a slow learner - I must be or by now I would be a rich plumber or electrician). Eoin

Hi Guys, Sounds like here in the old days before the european directive Dir 2002-98-EC which became law and the setting up of a national haemovigilance network (which covers haemovigilance and traceability). The procedure specifically precludes anything being given / introduced into the giving set. Thus this would be a reportable Adverse Event and if there was lysed cells infused, would also cause some changes in the patient and thus would be an Adverse Reaction as well, either reportable to the National Haemovigilance Network, who would probably pass this on to the Irish Medicines Board (who are the licence regulators by law) - different body in the UK I know. If you guys over there are interested, I could give a synopsis of the whole system (e.g. tracing from vein to vein - keeping records for 30 years, the haemovigilance and quality setups etc) and attach to a post in this forum. Cheers Eoin

Hi DAwn, Our Transfusion Committee meets quarterly. Members are the Clinical Heamatologist (Service Director), Laboratory Services Manager, Chief Scientist Bloodbank, BB Quality Manager, Haemovigilance Officer, Hospital Best Practice Manager, Nurse Development Co-ordinator, Director of Nursing (or her deputy), Nursing Reprsentative (CNM I), Anaesthetist, Surgical Consultant, Consultant Physician. If you email me (click on my name to the left)with your work email, I will happily send you a template for our meeting agenda. Cheers Eoin

So long as the clinical notes of the anaesthetist have been critically assessed at audit, are clearly referenced in the audit, and could easily be found by an external auditor who would concur with the sudit findings then there is no problem. Like others here, I find anaesthetists are meticulous in their recording of patient status throughout any procedure. Cheers Eoin

Welcome QCDan, After 40 years in Blood Banking, I have sidestepped into Quality. They say you can't teach an old dog new tricks, but I say you learn something new every day. Always something to learn on the forums, and I am sure you will enjoy. Don't be afraid to post. It is great to get feedback on a problem and without exception all here are willing to help if possible. Cheers Eoin

We allow Nursing, Care Assistants and Porters to collect - but only after training and competency assessment and we do have BloodTrack. Cheers Eoin

Hi Adiecast, Sorry for late answer, but have been on the other side of the hosp scene with viral pneumonia. We normally get our cells from Ortho supplier here in Ieland, but they are shipped via air from USA. The cells were getting close to outdating and in low quantitiy. Another alternative I spoke to some folks about was flying to another city in Europe and trucking them on - the cold chain maintenance might be a problem for the company though. I have been put on to an alternative source for other cells in England, so may well get some in and validate. Cheers Eoin