John C. Staley

Unless something has changed recently which I am not aware of, (the amount of info that changes daily that I am not aware of is truly staggering) a FDA inspector would be very unlikely to consider your use of coolers as transport.  They would be more likely to consider them storage and therefore insist on a storage temp range of 1 - 6 oC.  Especially since the blood is not packed by you and does not leave the blood bank in the coolers. 

We would "honor" a RhIG anti-D as the real thing until it dropped below detectable levels then we forgot about it.  As long as it showed up in the antibody screen we would perform AHG XM. 

Malcolm, were the fire trucks still hand pumped and pulled by horses back then?  Do you remember the name of the Dalmation that rode along?  By the way, what was the purpose of the Dalmation? 

Dar all
I was not suggesting that in general it is not necessary to crossmatch when antibodies are present. Nor was I suggesting that anyone ignore their SOPs, or that you need 1 SOP for patients with anti-D and another one for the other cases. Of course, a crossmatch should be carried out if an antibody is present, and for good reasons. However, in this case it was not - erroneously. What I was trying to do was look at how much of a risk the patient had actually been put to in this case, and concluded that actually the real risk in this case was almost non-existant. In another situation that might not have been the case. I think the most important thing to do here is instigate some serious training in the lab to make sure that everyone is aware of the importance of following SOPs. I still maintain, though, that in real terms and in this case, this patient's safety was compromised less than it would have been done by panicking the staff into stopping the transfusion..

Well, what was the true patient risk here? You know the patient had an anti-D. I presume that at the time of identifying the anti-D you did a proper identification with your exclusions and inclusions. So what other antibodies could be present? A possible antibody against a private. If your panel is not capable of excluding other 'common' antibodies in the presence of anti-D (I am sure it is) then you should change your supplier. So then there is the risk that your units of blood are weak or partial D and not true D neg units. Don't your blood suppliers check that? Of course, they could have made a mistake, but what are the real chances of that? And, if you check your units (not necessary in every country) don't you check then when they arrive?
So the real patient risk is absolutely minute in this case. On the other hand, I can well imagine that stopping the transfusion half-way through could give rise to a lot of unneccessary panic and increase the risk of errors because the team carrying out the transfusion had been panicked.
On the other hand, such a situation should not be allowed to happen again - in another situation, the risk might be more real. Therefore I would not beat myself up about what was already done but I would calmy look at the existing procedures, including training, and improve them.

Question for you.  Was the antibody screen / antibody ID positive ONLY for anti-D?  If so, I would probably have done just as you did. (Hard to say without actually facing the situation)  On the other hand, had there been any indications of additional antibodies I would certainly have contacted the nursing unit. 

On a slight tangent, I have never seen a blood bag that could be broken by simply dropping it.  At one facility we bagged them in paper sacks.  The administration thought that friends and family of patients might be disturbed at the sight of units of blood being carried through the hospital! 
 
I have, however seen one explode,  I was packing a unit of whole blood in one of the old spring loaded presses.  As I was slowly rasing the lever I was distracted and the lever slipped out of my hand at the beginning of the process.  The plate that, normally, gently squeezes the blood bag slammed into the unit with such force it ruptured the top seam and blood covered the walls as well as myself.  We had most of it cleaned up when a new house keeper arrived.  She took one look at the blood dripping from the ceiling and running down the walls, turned into the closest bath room, threw up repeatedly and then left.  No one ever saw her again. 

Apparently the bags I saw dropped were tougher than most.  Or they just don't make them like they used to.  (Now I am sounding my age!) 

The last (and only) one I went to was in 2000 at Vienna.  Had a great time and would love to go back.  That year I had a poster presentation on Automation in the Transfusion Service so Immucor helped foot the bill.  I was actually surprised how many folk I knew who were there.  Had a good long discussion with John Judd.  I recommend it to anyone who can swing the trip.

If you do finish the testing it will be for purely academic reasons and you should not bill anyone for it. That's my 2 cents worth.

Unless it was something "real serious" I would generally let the little stuff slide ONCE with seldom more than a friendly reminder, if that, especially if I knew the person committing the infraction really knew better.  What I actually tried to focus on were trends and repeats and if more than one person seemed to be making the same mistakes. 

On a slight tangent, I have never seen a blood bag that could be broken by simply dropping it.  At one facility we bagged them in paper sacks.  The administration thought that friends and family of patients might be disturbed at the sight of units of blood being carried through the hospital! 
 
I have, however seen one explode,  I was packing a unit of whole blood in one of the old spring loaded presses.  As I was slowly rasing the lever I was distracted and the lever slipped out of my hand at the beginning of the process.  The plate that, normally, gently squeezes the blood bag slammed into the unit with such force it ruptured the top seam and blood covered the walls as well as myself.  We had most of it cleaned up when a new house keeper arrived.  She took one look at the blood dripping from the ceiling and running down the walls, turned into the closest bath room, threw up repeatedly and then left.  No one ever saw her again. 

On a slight tangent, I have never seen a blood bag that could be broken by simply dropping it.  At one facility we bagged them in paper sacks.  The administration thought that friends and family of patients might be disturbed at the sight of units of blood being carried through the hospital! 
 
I have, however seen one explode,  I was packing a unit of whole blood in one of the old spring loaded presses.  As I was slowly rasing the lever I was distracted and the lever slipped out of my hand at the beginning of the process.  The plate that, normally, gently squeezes the blood bag slammed into the unit with such force it ruptured the top seam and blood covered the walls as well as myself.  We had most of it cleaned up when a new house keeper arrived.  She took one look at the blood dripping from the ceiling and running down the walls, turned into the closest bath room, threw up repeatedly and then left.  No one ever saw her again. 

On a slight tangent, I have never seen a blood bag that could be broken by simply dropping it.  At one facility we bagged them in paper sacks.  The administration thought that friends and family of patients might be disturbed at the sight of units of blood being carried through the hospital! 
 
I have, however seen one explode,  I was packing a unit of whole blood in one of the old spring loaded presses.  As I was slowly rasing the lever I was distracted and the lever slipped out of my hand at the beginning of the process.  The plate that, normally, gently squeezes the blood bag slammed into the unit with such force it ruptured the top seam and blood covered the walls as well as myself.  We had most of it cleaned up when a new house keeper arrived.  She took one look at the blood dripping from the ceiling and running down the walls, turned into the closest bath room, threw up repeatedly and then left.  No one ever saw her again. 

On a slight tangent, I have never seen a blood bag that could be broken by simply dropping it.  At one facility we bagged them in paper sacks.  The administration thought that friends and family of patients might be disturbed at the sight of units of blood being carried through the hospital! 
 
I have, however seen one explode,  I was packing a unit of whole blood in one of the old spring loaded presses.  As I was slowly rasing the lever I was distracted and the lever slipped out of my hand at the beginning of the process.  The plate that, normally, gently squeezes the blood bag slammed into the unit with such force it ruptured the top seam and blood covered the walls as well as myself.  We had most of it cleaned up when a new house keeper arrived.  She took one look at the blood dripping from the ceiling and running down the walls, turned into the closest bath room, threw up repeatedly and then left.  No one ever saw her again. 

On a slight tangent, I have never seen a blood bag that could be broken by simply dropping it.  At one facility we bagged them in paper sacks.  The administration thought that friends and family of patients might be disturbed at the sight of units of blood being carried through the hospital! 
 
I have, however seen one explode,  I was packing a unit of whole blood in one of the old spring loaded presses.  As I was slowly rasing the lever I was distracted and the lever slipped out of my hand at the beginning of the process.  The plate that, normally, gently squeezes the blood bag slammed into the unit with such force it ruptured the top seam and blood covered the walls as well as myself.  We had most of it cleaned up when a new house keeper arrived.  She took one look at the blood dripping from the ceiling and running down the walls, turned into the closest bath room, threw up repeatedly and then left.  No one ever saw her again. 

On a slight tangent, I have never seen a blood bag that could be broken by simply dropping it.  At one facility we bagged them in paper sacks.  The administration thought that friends and family of patients might be disturbed at the sight of units of blood being carried through the hospital! 
 
I have, however seen one explode,  I was packing a unit of whole blood in one of the old spring loaded presses.  As I was slowly rasing the lever I was distracted and the lever slipped out of my hand at the beginning of the process.  The plate that, normally, gently squeezes the blood bag slammed into the unit with such force it ruptured the top seam and blood covered the walls as well as myself.  We had most of it cleaned up when a new house keeper arrived.  She took one look at the blood dripping from the ceiling and running down the walls, turned into the closest bath room, threw up repeatedly and then left.  No one ever saw her again. 

No, no, no, NO and most definetly NO!! I fought long and hard against a blood bank specific armband. It complicates a process that can be simple and efficient. It is often a fall back when training and education will be "too difficult".
Ok, I'll get down of my soap box now.

Just a note from personal experience. My wife, a nurse of course, has, amoung her other antibodies, anti-D. This developed due to the birth of our son. (Long story I won't burden you with here.) Four years later our daughter was born 6 weeks early and required a double exchange transfusion due to the anti-D. This little girl is now 27 with 2 kids of her own. Having anti-D is not nearly as devastating as it once was. Please keep us posted. You have our interest.

Eoin, I like it.  Short, sweet and to the point, as long as I'm (the blood bank) not responsible for explaining it and getting it signed or making sure it gets signed.  This is a clinician responsibility. 

One of the things that frustrated me the most towards the end of my career in blood banking was being thrust into the position of the "blood police".  We really were not in a position to accomplish a number of the tasks that were forced down out throats.  Trying to explain why this was not a good idea only got us labeled as not being team players.  This is about the only aspect of blood banking I don't miss! 

Just a thought. SHOULD does not equal SHALL. I know that's been a bone of contention for many years but the word should does give you some latitude. :raincloud :raincloud

I'm reasonably certain that no one here is "saying there is no risk". What most of us are saying is that, often the risk to the individual trauma patient is much more academic than real. The real risk for most of us is not having the Rh negative blood for a patient that really NEEDS it because it all went to a patient who would have done just fine, ie survived, with Rh positive blood.
If you have the luxury of not having to worry about inventory levels of O Neg RBCs then more power to you. Most of us have not, do not and never will live in such an enviroment. We owe it to all of our patients to be the best stewards of the resource we can possibly be. We live in an imperfect world.
:juggle:

No, no, no, NO and most definetly NO!! I fought long and hard against a blood bank specific armband. It complicates a process that can be simple and efficient. It is often a fall back when training and education will be "too difficult".
Ok, I'll get down of my soap box now.

My thoughts are to keep it simple. When you have a process and then try to define exceptions to that process it provides more opportunity for errors. It was the same concept we had with Autologous units. We were not required to do any infectious disease testing on them but it was easier and more consistant to treat all donor units the same than it was to try to keep track of the ones that did not need the testing.
While I certainly agree with the logic of not testing both bags of a double unit and I would lean towards all or nothing. If you are going to require the crossmatch for both bags then require everything otherwise you are leaving your staff open to confusion especially when pressed for time.