John C. Staley

Just a thought on the IS xm that has not been mentioned. How many of you have had old or immuncompromised patients who do not reverse type on immediate spin and would most likely have a compatible IS crossmatch with an incompatible unit? There is a lot to this scenerio that may never be known because of the way it was handled. While getting rid of the people may give the impression of "doing something" it seldom identifies, let alone, solves the problem. Granted, this is a stretch but it is something that should have be determined if it was not. :raincloud

Any one still wonder why there is a shortage of techs and no one wanting to come into the profession, especially Transfusion Medicine? When the pressure to pay ratio is as one sided as this occurrence shows, it's no wonder we are are a vanishing breed. As long as humans are involved human error will occur. There is simply no getting around it. As long as negligence or wilfull misconduct can not be proven then we should give them the benefit of the doubt. No one has mentioned the work load these two were under. How many shifts/hours have they been working do to short staffing? There are too many factors we don't know but they all contribute to someone's ability to perform. I am currently down 20% of my work force and when you only have 8 to start with that's significant. One night tech is working 11 on 3 off until someone can be hired and trained to be his opposite on a 7 on 7 off. Others are pulling extra shifts as well. I certainly hope nothing like described above happens and we do have some safety features built into our computer system to help prevent it but it could happen. To me that's an indication of over work and over stressed and something else needs to be done if possible but certainly not a reason to terminate anyone as long as gross negligence can not be proven. This, to me, is a clear justification for computerization for the facility involved. A computer system will cost a fraction of the law suit and settlement.

I would like to add a question to this thread. Do you attach irreversible temperature indicators to each unit of blood in the cooler? We do and it's a nightmare. The nurses pull the units out of the cooler and go through the ID process and claim to put the blood back in the cooler right away. Then when the unused blood comes back half the temp indicators have changed color and are thrown way. This has really become an issue since coolers became storage and not transport and we are using indicators that change at 6oC instead of 10oC. It's hard to get the indicators on the units and into the cooler before they change.

Based on the info you provided, absolutely not. There has to be more to it. Other things going on, distractions not accounted for. How many other tests were running in the rest of the lab at the same time. I agree with Bev that my biggest concern is with the second tech and the IS crossmatch. That is a little fishy but I would still want more info before making any radical moves. You may have just been handed the best reason for either a computer system, automated pre-transfusion anaylzer or both. :eyepoppin

1. Do you retype a specimen everytime it is touched. For example if day shift does the crossmatch and you come later and do a add-on do you retype the specimne? If so is it documented? Currently yes, with the new computer system we are installing NO. 2. If you are doing this are you also doing some sort of documented second type? No 3. Do you do a DAT on all crossmatch specimens? NO!!!! 4. What sort of facility are you? 300 - 350 beds, level 2 trauma center with full service for just about everything but transplants. :fingerscr

Even with a low titer there is no guarantee that the Anti-D is from the Rhogam. It most likely is and will probably go away in the next few weeks or months. If it does go away that soon you can be pretty confident that it was from the shot.

One of my more experienced staff members who is new to the team has been telling a couple of the staff who are less experienced that if a baby is wD positive they should do a KB stain instead of a Gamma Fetal Screen becasue of the wD being a weaker expression and may therefore give a false negative fetal screen result. Before I ask her about it I thought I would run it past you folks. I can't fault the logic but I've never heard such a thing and can not find it referenced in the Gamma Fetal Screen package insert. Anyone else familiar with this train of thought? :raincloud

Thanks everyone. I appreciate the input. I now have suggestions to help ease the change forward.

We are trying to standardize our bagtags corporate wide due to a new computer system coming online. One of the problems is the "bagtags". To make a long story short the best system for us would be a single copy form that gets posted in the chart and nothing is returned to the Transfusion Service after the transfusion is completed. A few of the supervisors are concerned that if they don't get anything back how can they monitor the transfusions like they have been doing for years and years and years and years. I have not had anything sent back for over 5 years. I currently do a one month audit of every product transfused during that month, twice a year. What are those of you who don't get anything back do, if anything in the way of audits so I can provide these folks with suggestions. They think my system is tooooo much work.

I'm afraid in the grand scheme of things in the world of healthcare blood bank reagent prices are not even on the radar. Priced a new MRI or CT machine lately?? How 'bout a new chemistry analyzer?? To be honest the price of reagents is the least of my worrys. Now, wheather or not the blood supplier can fill my next order!! Or will I find someone to replace the tech that's retiring soon. That's something to worry about. Pick you poison.

I met with our heart surgeons last Thursday and they have already jumped on the bandwagon. They don't care about supply, they don't care about any other patients, they don't care that we don't draw donors and are held captive by our blood supplier. They want blood less than 14 days old (actually they really want < 10 days) now and nothing else will be acceptable. We'll do the best we can but that's all I promised.

Two questions before I attempt to give you an answer. Do you utilize a computer system for documenting the issue of the blood products? Do you have the capability of issue blood products via pneumatic tube system? :juggle:

Our policy is to avoid finding cold agglutinins at all cost. We have a very active open heart program, just about everything except transplants, and have never been asked about cold aglutinins. They did just read the study about fresh blood and that's going to be a problem but they have never been concerned with cold antibodies, thank goodness.

Linda, I just looked closer at the "rotator" and noticed it doesn't "rotate" it just sloshes the platelets back and forth. I could not check the RPMs if I wanted to because it, technically, doesn't have any Rs.

Any way you could share that OR specific transfusion form? I'm willing to bet that everyone has problems with OR compliance.

For adults, when we transfuse type O blood because we don't know the patient's type we will switch to the patient's type immediately upon obtaining the patients type. Why wait?

I'm curious, has any one actually ever done this? Treated an Rh pos transfusion to an Rh neg patient with massive doses of RhIG. Seems to me you would then have to treat a potentially severe transfusion reaction. Granted the hemolysis would be extravascular but there would be a considerable acceleration of RBC destruction going on. I have to wonder if it really would be better than doing nothing. Having an anti-D vs severe renal damage. Tough call. :lonely:

We have absolutely nothing to do with therapeutic phlebotomies. They are performed in IV Therapy by the nurses. We are completely out of the loop and see no reason to get involved.

We just installed a new Helmer incubator/rotator and I did not find any mention in the operator manual about RPM checks so I don't have any intention of doing them. Did not even consider the need.

Hey ruts are good, they keep us from falling off the cliff. I've been monitoring the amount in $$$ blood waste is costing the facility. It's broken out by nursing unit. It's pretty interesting the kind of responses you get when administration sees the $$$ being wasted by certain departments (ER). Of course ER's response is always, we don't care about money we're saving lives!!

Another question that should be asked to compliment this poll is how many answering NO are doing a second type on the original sample.

Gil that is a pretty strong statement. I would take issue with any of my techs making it if there is no evidence of a RhIG injection in the recent past. :abduction

That variety of cut-off times seems to come from the comfort level of the individual supervisor and/or medical director, their back ground and experiences. If I remember right the University of Michigan Transfusion Service did some studies on this quite awhile ago and that's where I first heard of the protocol I described above. I'm not sure where the data would be found but I would not be surprised if it is in a TRANSFUSION issue some where. :coffeecup

If you are interested, the 24 ed of AABB Stds 5.13.3.3 states: "In patients with previously identified clinically significant antibodies, methods of testing shall be those that identify additional clinically significant antibodies." I imagine CAP has something similar but I'll let someone else find that if they want. There are a number of ways this is interpreted. My favorite is that you repeat the antibody screen everytime you get a new sample to see if the pattern of screening cells indicates a change and AHG crossmatch antigen negative units for the known antibody. If they are compatible you are good to go. If they are incompatible you do what is necessary to discover why. A number of facilities follow this policy, a number of others find it appalling that anyone would consider it.

Yes we do an AHG crossmatch for a patient with anti-D. This includes RhIG anti-D as long as it is detectable. We do not wD test the units. It never occurred to us to test them for wD for this reason. Unless things have changed since I was in the donor side of the business, the donor center has wD tested the units prior to labeling them as D neg. I see no reason to repeat that testing just because the patient has an anti-D.