John C. Staley

Just a thought that maybe your process is more complicated than it really needs to be and the nursing staff fail to see the need for it to be so complicated beyond you telling them that's how is has to be done. Sorry but I have never been a fan of blood bank specific arm bands or blood samples (pink top tubes). If I said it once I've said it hundreds of times, complicating a process NEVER makes it better. My first blood bank supervisor, bless her heart, instilled in me the importance of the KISS principle: Keep It Simple Stupid! and I tried my best to adhere to it even in the face of adversity (corporate Transfusion QA)!! OK, I'll get off my soap box before I fall off.

Not sure how I missed this discussion when it first came out but here's my 2 cents worth. It is the physicians responsibility to inform the patients of ALL risk / benefits of every aspect of their treatment to include transfusions of any and all blood products! Granted, this is not always possible due to the situation but that does not absolve the physician of the responsibility! In no way should this responsibility ever be dumped on anyone else.

Before I answered the question I wanted to wait and see what other people had to say. BankerGirl, thank you for your last sentence. It is a philosophy I had followed all of my career. I understand the argument that everyone is responsible for the patient's well being but at some point you have to draw the line and make everyone responsible for their piece of the process.

Just curious Malcolm and Steve but how soon after completion of the transfusion do you check the Hgb/Hct? Back in the day there was quite a debate going on and I don't remember it ever being resolved. One study I remember indicated that in order to get an accurate determination you needed to wait 24 hours to let the blood volume equilibrate while another indicated that 1 hour or even less was adequate to determine if additional units were needed. Also around this same time the general philosophy was if you needed only 1 unit you really didn't need any. Consequently we rarely if ever gave less than 2. It was about the time I got out of blood banking that, as Malcolm indicated, why give 2 when 1 will do started to become prevalent.

We always did it in the blood bank until the local University Medical Center Lab offered flow cytometry. We still kept a kit around and maintained competency for the emergency situations a physician wanted to know if the blood they are dealing with is mom's or baby's. Never really thought it was that big of a deal to make the battle worth fighting.

Just curious, is it still acceptable to provide males and women "older than child bearing age" (we used 55 as the cut off) with O pos units in an emergency situation preventing an unnecessary drain on the very limited O neg supply?

If your state requires medical laboratory professionals to be licensed I would look there first to see what or if there are any restrictions as to who can do what. I'm fairly certain that, unless things have changed drastically is the past few years, organizations such as AABB, CAP, JCHO (or what ever they call themselves now) and even the FDA only require you to show who ever is doing the testing is competent. Just my thoughts on the subject and my info may be out of date.

I suggest you take a moment and determine exactly why you want a second type. Is it simply to be able to meet some outside requirement? Is it to detect the possibility of a testing or clerical error at the bench or is it to determine if the blood in the tube did not come from the patient the test was ordered for? While each of these is a worthy goal, by my way of thinking only one way will achieve all 3 and that is a second sample collected at a different draw. Now you can get even more complicated if you want depending on your level of paranoia. Must that second sample be collected specifically for this purpose or can you "borrow" one from hematology? Must that sample be collected by a second individual or does that matter? Must that 2nd collecting individual be left handed because the original collector was right handed? Lastly you must determine what are the actual limitations imposed by your facility for each shift. Are you a small facility without the staff on all shifts to actually have a second sample drawn by a second person? Take the time to really consider all of this and then keep it as simple as you possibly can. No one ever improved anything by making it more complicated.

The key here is they came to Linda and asked for help!

What I quickly realized was that no 2 inspectors/assessors focus on the same thing. As David noted, they seemed to focus on things they were either cited for or had cited others for recently. Over the years I had been cited for something that had passed all previous inspections because the inspector simply did not like the way we did it. When I challenged the citation with the inspecting organization the citation was often over ruled, not always but often enough to make the challenge worth while. My best advice is to prepare the best you can and consider the inspections a learning experience and hope that David is your next inspector. On a side note I was a Blood Bank inspector for CAP for 30 years so I had ample experience on both sides. One last bit of advice, never ever argue with an FDA inspector!

I'm with David on this. Why do you want to be that involved in something you have absolutely no control or authority over??

One possibility is state regulations on who can do what testing and the decision to train someone has been taken out of their hands. Now I'm going to get on my soap box and please don't take this too personally. There is a very big difference between training and teaching. Over the many years I have trained more people in blood bank than I care to remember. Every one of them had the basic knowledge and understanding of what was going on in the testing and knew at least one way of doing the testing. I was training them to do it our way, not teaching them the principles and background of the testing. It is simple enough to train some one to add A and B to tube C, spin for 15 seconds, shake the tube and see if it clumps but that is not teaching them anything about the testing or what to do if it doesn't work as expected. With out the basic knowledge behind the testing and processes you would find it nearly impossible to pass the BB test. I am curious, just exactly what have you been doing in the Blood Bank for the past few years? I know organizations that will allow only MT/CLS registered staff work in the Blood Bank and exclude even MLTs. My suggestion to you would be to find a program that fits your needs and complete at least the MLT level education. Another option would be to find a facility that still offers internships if there are any. They are set up to provide the training and education you are requesting from your current employer. I'm afraid this is probably not the response you were hoping for.

Thanks Malcolm. I'll see if I can locate a copy.

My thought as well. Mostly the why.

In other words, who accredits the accrediting agencies? There you go Malcolm living in that imaginary perfect world.

You might want to check with the state, and/or national nurse organizations for this information. They are the ones generally in charge of nursing practice. Another place to look would be JCHO (or what ever they are calling themselves now). They may have the information you are looking for. Lab organizations such as CAP and AABB are reluctant to make rules or requirements telling nurses what to do.

When I first read the original question shortly after it was posted my immediate response was, "clumping". I had missed the word grading. I decided to wait to see what other responses would be. I think why I missed the word grading is because we never graded the coombs control cells. Either they clumped or they didn't. Simple as that. As noted above, all you are doing is confirming both that you added the AHG and it is working. That's about as simple as anything we ever did.

Personally, I find this quite disturbing!

I think she's referring to a Masters of Laboratory Science. I think it is available at a few Universities. LisaMarie, I can't answer your question, if I am interpreting it correctly, but...... many years ago when I was considering getting my SBB. I had a lab director tell me that he didn't care how many degrees I had or how many letters I had after my name, he wouldn't pay me any more. At that time I was supporting my young family so I elected not to pursue it. Not too many years later I move on to another facility. After 35+ years in healthcare I can say with confidence, any thing you can do to increase your knowledge and credentials will open doors that will otherwise be closed to you.

I probably shouldn't go here but I'm curious. You said that you recently started working at a hospital blood bank, how long is recently? You also state that you want to revise the QC policy, are you the supervisor or medical director at this facility?

Just curious Malcolm but what is considered naturally high level of potassium vs unnaturally high levels? How much investigation goes into determining it?

In 35+ years I saw a few. Two of them come to mind. The worst case of HDN I saw was due to Anti: c. The other was my daughter due to Anti:D. I had one pediatrician who did them with alarming frequency, he wasn't around very long. The 2 facilities I worked in where exchanges were done were 250-300 beds (depends on who was counting and why). The latter of the two had a large NICU (don't remember the count but I think it was 35 or 40). My initial response when first reading the question was, when necessary. As noted above by everyone, it is infrequent to rare mainly due to the excellent prenatal care currently available.

This is not a popular concept but at some point we have to accept there are things we can not control. Once the blood leaves the blood bank we are at the mercy of other humans and as long as the human factor is involved there will be human error be it unintentional or intentional. Attempting to complicate a process will only provide inventive humans the opportunity of coming up with creative work arounds to circumvent your best of intentions. At some point you just have to step back, do your job and hope for the best. I had a corporate transfusion QA director who could not accept that human error could not be completely eliminated with out eliminating human involvement in the process. Her directives became horribly complex solutions with multiple, redundant checks and balances only resulting in increasing problems. Bottom line, pick your battles and fight those you have a reasonable chance of winning. Make suggestions, offer insight, provide training opportunities but at the end of the day realize that you have to accept some things are simply beyond your control and even your influence. On that happy note I'll step off my soap box and stop my philosophical ramblings.

Just out of curiosity, what prompted this question? In my experience most facilities have a Risk Management Department which is usually headed and staffed with nurses. They would be most interested in any noncompliance in the facility.

I'm pretty sure any of the commercial QC systems will have this covered and I don't remember them being all that expensive. I have used both the Ortho and Immucor systems and don't remember any issues.