20 hours ago, David Saikin said:

right next to your post is an ad for digitrax temp-check.

I do not accept returns after 15 minutes.  My study shows rbcs achieve >10C after that amount of time.

I used something similar but about 30 years older!!!  Glad to see it's been up graded.  I had a number of inspectors that did not like it because they had never seen anything like it.  They couldn't say to much about it, I had all the records showing it was verified just like all the rest of my thermometers on the same schedule. 

I've been searching for the powerpoint I made of the occurrence I wanted to share but I must have stored it on an external hard drive that crashed and was unrecoverable.  (That's my excuse anyway.)  Consequently it was long ago and my memory is fuzzy on the details but in this case the details is not the point I'm attempting to convey.  Bottom line was that 2 units of blood were sent via pneumatic tube to ICU for 2 different patients. No, the units were not in the same tube, they were sent 10-15 minutes apart.  The units went to the wrong patients and the proper patient identification protocol was not followed.  Both units were transfused and the paper work was sent back to the transfusion service.  I do remember a very white faced staff member coming to my door to tell me what they had discovered.  Luckily both patients were type O+ with no problems and recrossmatching showed that each was compatible with the unit they had received. We had dodged a bullet!  The ensuing investigation discovered that the patient identification protocol used by the ICU nursing staff had morphed into something I did not even recognize.  A couple of years earlier the nursing department had taken over all training of new nurses as well as annual reviews for current staff.  They basically told me my services were no longer needed in a training capacity.  When the details of the occurrence came out the assistant CNO (chief nursing officer) who was filling in for the CNO on sick leave wanted to severely punish the two nurses involved and then sweep everything under the rug.  Heaven forbid that word got out that a couple of HER nurses had made a mistake.  Much to my surprise and delight I was able to convince the ICU nurse supervisor that the problem was much deeper than just human error and the protocols the nurses were following were deeply flawed.  We did extensive retraining for the entire ICU staff.  When the CNO returned to duty I had a long talk with her. I had always had a very good relationship with her and she trusted me.  From that point on I was actively involved in the training a new nurses as well as the annual refresher courses for current staff.  During those training sessions I was not surprised that other areas had "adjusted" the pretransfusion patient identification protocols to be easier and quicker for them.  Using this occurrence as an example I was able to convince them of just how critical patient identification was.   

As a side note, I one time had a labor and delivery nurse tell me that it was impossible for her to transfuse the wrong blood to her patient and nothing I could say would convince her otherwise.  Some times I wonder how I ever got out with my sanity intact!  My wife (a nurse) reminds me that I didn't!

 

21 hours ago, Malcolm Needs said:

For all I have said above, and I think I have said this before on here, when I was first working in Red Cell Reference, when the International Blood Group Reference Laboratory was in London, and the Department was run by Carolyn Giles and a very young Senior Technician by the name of Joyce Poole, I also had the problem of seeing "weak agglutination" that wasn't actually there (totally negative, in other words), and Joyce coined this as a "Malcolm Weak".  This was way back in the early 1970's.
I understand that, now and again, some 50 years on, the term is still used in the department for over enthusiastic reading of reactions!!!!!!!

It's good to be famous and remembered!!  

When tube testing was all we had, my moto was; "when in doubt, shake it out!"  One of the first things I did as transfusion supervisor at a new facility was convince the medical director that we needed to stop using the microscope for routine testing.  It was much harder to convince the rest of the staff.  I couldn't remove the microscopes from the department because we were doing KBs at the time and I'm pretty sure a few of the "older" staff still used them for routine testing when I wasn't looking.  Once again inertia is proven to be the most powerful force in the universe!

 

I had always found it difficult to convince nurses that we were working with a person/patient and not a room/bed!  This became even more difficult after all the privacy rules and regulations came about.  It was almost as if they were terrified to say a patient's name aloud!

I especially like the way you phrased it as "transfusion error stories" and not transfusion horror stories.  Looking back I sometimes think I could write a book on the subject.  Well, maybe not a book but at least a novella!  Some of the stories would be comical and others terrifying.  Luckily, in over 35 years in the business none of my stories are fatal but a few had the potential.

 

Regardless of all the possible causes along the way the ultimate human failure occurred at the bed side!!  People are probably getting tired of me saying this but as long as there are humans involved in a process human error will occur.  All we can hope to accomplish is minimizing both the number of times it occurs and the resulting ramifications.

 

9 hours ago, mrmic said:

Just a note of caution. The only issue that was observed with pneumatic blood transport was the following; A tech sent a crossmatched, tagged unit of red cells to the 5th floor nurses station for patient A.  Twenty minutes later a tech sent a crossmatched, tagged unit of red cells to the 2nd floor nursing station for patient B.  A few minutes later the 2nd floor nurse called the TS lab and indicated they had already received the red cell unit for their patient B and did not need the 2nd one.  ?? That's right, the first unit that was to go to the 5th floor was misdirected by the tube system and went to the 2nd floor.  Since the 2nd floor nurse was expecting a rbc unit for her patient, the unit was started and being transfused.  

 

 

Sadly, I can't open the attachment of the answer.  I was hoping to see what was considered "critical thinking".  From the responses of others it would appear I am not missing much.  

Carry on folks.

9 hours ago, JeanB said:

@Kathyang Hi Kathy, thanks for responding. Yes, 72 hours is 3 days, but I guess in Soft it would expire right at 23:59 of the 3rd day. I had actually just figured out the solution to this - go under Products Order Service>Finish. 

Not to be too nit picky but while 72 hours is 3 days, depending on who is counting and why, 3 days could be anywhere between 48 hours 1 minute and 72 hours.  Just thought I'd mention that.

Glad you got the computer figured out.  It can be no easy task.

I would also like to see the definition of critical thinking used by the original question setter.  That might help trying to understand what they were getting at.  I know from past question writing experience for students, that an answer which I considered so blindingly obvious was in fact not anything of the sort. 

Malcolm's answer seems reasonable but I'm with you that all the original question does for me is lead to more questions and no answer.  Such as; what does "Investigation of the label issued at the blood bank verified the unit's correct labeling." actually mean??  Was this a real case or just something someone made up?

My only recommendation is, what ever process you decide on, keep it as simple as possible.  On first thought I would keep everything in-house.  By that I mean you do all the testing and transporting.  At least with these patients you know they will be transfused and the chance of a unit being wasted is very small.  It may not be convenient but it is simple.

I have no answers to your questions but instead have a question for you.  Are you aware of any bad outcomes which could have been the result of the practice at your facility?  

Is there someplace local that can do flow cytometry for you.  I never understood why everyone thought KBs are so difficult.  We were forced to stop doing KBs and send out for flow cytometry by the corporate transfusion service medical director.  I have my suspicions why but I won't voice them here.  We never had any issues with doing the KBs and we really didn't do all that many.

Where was that when I was still working!!!  Would have worn it to work everyday.

 

17 hours ago, Malcolm Needs said:

I, too, am DCe/DCe (R1R1).  This is getting spooky!  Maybe you are on to something exlimey, and should write it up for Vox Sanguinis, Transfusion and/or Transfusion Medicine, or maybe even Nature!

Thankfully I'm R1R2!!!!  

Couple of more strange questions, how sure are you that it is anti-Jka?  If you are sure, why were you doing a ficin panel?  

Can't wait to see what Malcolm has to say.  

I guess I've been out for too long, what is "pathogen reduced platelets"?  If I remember correctly we used to refer to leuko filtered RBCs as reduced risk for CMV but I don't remember doing anything for platelets.

Thanks Malcolm, I'm sure the acknowledgements are both prestigious and well earned.  Again, congratulations. 

 

Malcolm, I'm always hesitant to show my ignorance but what is the difference between a Life Membership and a Fellowship?

As long as humans are involved in a process there will be human error!  You best option, as suggested above by jinsat is to have the product ordable by the physician.  Remember, complicating a process never makes it better.  

Congratulations.  

5 hours ago, Malcolm Needs said:

Infamous??????????????????????????  

I would have used Notorious!!  

13 hours ago, JeanB said:

I am really curious what your experiences are when it comes to being promoted internally vs getting hired from another facility. 

Ok, here we go.  First is from a personnel stand point.  When promoted from with in you are no longer "one of the guys".  This means that some of the staff will try to leverage your close friendship which in turn will cause problems with others.  Both you and the rest of the staff need to recognize that things have changed on a personal level, at least in the work place.  This does not have to be dramatic and should not be, but it is real.  Some can do this and some find it very difficult.  Now, when coming from outside your are exactly that, an outsider.  Now the level of this can vary immensely depending on the situation.  One time when I changed facilities it was just across town and I new many of the staff at the new facility so a lot of the unknowns were minimized.  On the other hand, I also moved to another facility out of state and pretty much walked into an unknown from a staffing standpoint except for what little I could glean from the interview.   As I noted in my previous post, be very judicious when using the phrase, "this is how we did it."  I've had new employees who would say this at every opportunity and then go into detail about how we were either doing it wrong and that their way was just much better.  This became very trying to everyone else on the staff and we finally just tuned them out.  Because of that we probably did miss out on some good ideas.  One last point, in either case be aware of any others staff who may have either applied  for the position or simply been over looked.  Depending on their personality they can either be a great help or a significant hinderance.  Do everything you can to get them involved and engaged.  They can be your greatest asset but it may take a little extra work on your part.  For me, the personnel issues were always the most difficult. 

I'm assuming that you are new to the lead position and not knowing your previous experience here a couple of generalizations.  Unless something is an obvious hazard to either patients, staff or the ability to pass an impending inspection/assessment don't be in a big hurry to make changes.  As they say in the military, you need to understand the lay of the land.  Become familiar with the blood bank/transfusion service medical director and let them have the chance to become familiar with and confident in you.  They can and should be your greatest allies.  Ultimately most of what you want to change will have to be approved by them.  You need to understand the current processes before trying to change them.   At one of the facilities I moved to I noticed that many of the staff were not following their procedures "to the letter".  The way I dealt with this was at the monthly staff meeting we would go through a procedure as a group, line by line and I would ask the questions, "Is this how you are really doing it?  If not, why not and how are you actually doing it?"  This is when I would make suggestions for changes and generally a lively discussion would ensue.  It took quite awhile to go through the procedure manual but by picking, what I considered the most important  one first it was time well spent.  

This is getting a little long so I'll end with how I described my position as Transfusion Service Supervisor at a 350 bed level ll trauma center.  My job was to provide the staff with the tools (equipment, knowledge, material and support) for them to do their jobs at the highest level possible.  All this while keeping the dragons (administration) away from the door.  Good luck and if I can think and anything else that others may miss I share a few more golden nuggets of wisdom with you.  Above all else have faith in your self.  

     Wow I think that's the longest post I've ever made. 

19 hours ago, R1R2 said:

 Don't be afraid to change things that were always done that way.  

To this I will add, pick your battles carefully.  Make sure they are worth fighting.  If you came from outside the facility be very judicious when using the phrase, "The way we did it"!  Changing something to the way you did it else where is not necessarily a change for the better just because it makes you comfortable.  Make sure you understand your new facility's processes before trying to incorporate sweeping changes.  As I noted above, much of my advise would depend on if you came from outside or promoted from within.  This is just one golden nugget for you to consider.