Sandy L

It's a pretty interesting phenomenon. It sometimes seems like the entire hospital is run by a nursing council/committee, which can only be overruled by medical staff and even then, physicians don't always get the last word depending on the topic (though sometimes that's probably a good thing!). That is why it is absolutely essential to cultivate some key relationships with nurses in various disciplines. The team approach is preached but I think we - the lab - have to work very hard to be included in the team in a truly meaningful way. Always a work in progress.
The current thinking at my facility is that everything has to be focused on easing the life of the nurse so that they have the time to best care for their patients. I have no problem with doing what we can to improve patient care, but sometimes it puts us in some interesting job responsibilities as we 'ease their workload'. There also seems to be a mindset of 'Mother Knows Best' and of course Mother is a nurse. Often Mother does know best, but sometimes she needs to listen to advice.
Another issue is that many nurses do not truly know what the lab does and how, do not understand that we are tightly regulated and that we are actually well educated people. We often bump into issues where we have to say (very sweetly, of course) - I don't tell you how to do your job because I'm not educated to do your job (unless you are messing with my blood products!), so please do not tell me how to do mine.

We have a couple of policies that might have helped (although if the tech was convinced that the reactivity in solid phase was a false positive, he might still have missed this--our expectations are powerful).  We require (well, there are some exceptions) that 2 double dose (homozygous donor) Jka positive cells not react in gel before we can rule it out.  I have seen too many anti-Jka antibodies that react with one cell but not another in gel.  We pretty much never rule it out with just "positive" cells.  I know I look particularly hard at whether something "sort of" fits a Kidd antibody because of their tendency to be weak to undetectable.  If all of the positive reactions are on Kidd double-dose cells, I will be doing some extra work to rule it out.  Antigen type the patient, as Malcolm says.
We train and it is in our procedure that the gel card must be "QCd" after running which includes looking for proper centrifugation of the card and whether the cell and plasma volumes are correct.  I can't promise that no one ever gets lazy and skips this but then they are not following the procedure.  
Some other options would be that gel cards run to follow up on questionable solid phase results have to be incubated for 30 minutes instead of 15 (we have validated up to 40 minutes which is about the maximum allowed I believe in MTS gel).  This will sometimes bring out a weak antibody or make it react with more cells.  It does not change the non-specifics much usually.

Today my dear chap you win the internet! (again)

You could always irradiate the blood bag (as well as the blood), while the stupid nurse is holding it!!!

We call them passive - but all of our records are scanned now. Some poor MLA had to scan all of our historic records but now it gets done daily.

Mabel,
We used to see this when plasma was thawed but just barely beyond the "slushy" point so that the unit was still very cold when it came out of the waterbath..  You will have cryoprecipitate forming in the refrigerator.  It is sort of like the process where you make cryoprecipitate by thawing the FFP in the cold.

Hi Kelli,
I'm so excited to hear you are writing an article for Transfusion. Finding time to write is a challenge. I wouldn't worry about a professional reviewer as the Transfusion staff will edit your article to comply with the Transfusion Style Guide. As one of the former Technical Editors for Transfusion, I'm very familliar with the process. The journal's website which you can access through AABB.org, has instructions for authors that will cover how they would like you to organize your paper (Case Review or original work, etc) and the steps for electronic submission of the file once you are ready for the peer review process to start. The peer reviewers are only supposed to look at content and how you drew conclusions from your results. They will submit questions back to you if it is felt there is more explanation or data needed. This is meant to be a supportive, collaborative process so please do not take any of the comments personally. They are meant to help you look good as an author.
When content is settled, the technical editing staff for the journal will will work on your paper to make it comply with the Transfusion Style Guide and send you proofs before anything is printed. They do all the heavy work as far as grammar and formatting are concerned. They will make sure your data is presented in the clearest way possible and  that your intended message is delivered correctly. You will be involved in the process but not completely responsible for it so don't worry!
Any questions or concerns, I'm happy to help.

The scariest thing in the world is a nurse with a pair of scissors and an urgent need to use them.   

GD-CLN-900100.pdf
Hi, We are a multidis non-trauma hospital, with a large (10,000 births/year) maternity hospital. We have found the use of Cryo in the first MTP pack to be advantageous in getting obstetric bleeds under control more quickly. 

Based on John Judd's study, we changed our criteria to "transfused within 4 weeks" and based in his work we are still being overly conservative.

We, in the UK (and I think in Europe) have the cards shown below (and similar cards are available from other suppliers, such as Ortho, and they are FANTASTIC!

Another thing that I do for positive antibody samples when using outdated antiglobulin reacting antisera:  add a few drops of anti-A,B to turn the plasma into “group O” and then pick a panel cell for the cell suspension.  This would achieve the same thing as David’s mix of absc negative patient plasma’s.  Patient’s with positive absc’s are also a good source for unknowns.  Another source, once the reporting deadline for proficiency testing has passed, we re-assign proficiency samples (if quantity permits) as additional competency samples.  We try to get a much mileage as possible so we use these types of unknowns for ABID, antigen typing, titers, antibody screens in gel (automated and manual platforms) and tube testing.
For DAT’s, I will make a mix of outdated IgG sensitized Coombs Control cells and un-sensitized cells (outdated screening cell, etc.) to make a mixed field positive DAT.  Also I save outdated Complement sensitized Coombs Control cells for DAT unknowns.

Another thing that I do for positive antibody samples when using outdated antiglobulin reacting antisera:  add a few drops of anti-A,B to turn the plasma into “group O” and then pick a panel cell for the cell suspension.  This would achieve the same thing as David’s mix of absc negative patient plasma’s.  Patient’s with positive absc’s are also a good source for unknowns.  Another source, once the reporting deadline for proficiency testing has passed, we re-assign proficiency samples (if quantity permits) as additional competency samples.  We try to get a much mileage as possible so we use these types of unknowns for ABID, antigen typing, titers, antibody screens in gel (automated and manual platforms) and tube testing.
For DAT’s, I will make a mix of outdated IgG sensitized Coombs Control cells and un-sensitized cells (outdated screening cell, etc.) to make a mixed field positive DAT.  Also I save outdated Complement sensitized Coombs Control cells for DAT unknowns.

Another thing that I do for positive antibody samples when using outdated antiglobulin reacting antisera:  add a few drops of anti-A,B to turn the plasma into “group O” and then pick a panel cell for the cell suspension.  This would achieve the same thing as David’s mix of absc negative patient plasma’s.  Patient’s with positive absc’s are also a good source for unknowns.  Another source, once the reporting deadline for proficiency testing has passed, we re-assign proficiency samples (if quantity permits) as additional competency samples.  We try to get a much mileage as possible so we use these types of unknowns for ABID, antigen typing, titers, antibody screens in gel (automated and manual platforms) and tube testing.
For DAT’s, I will make a mix of outdated IgG sensitized Coombs Control cells and un-sensitized cells (outdated screening cell, etc.) to make a mixed field positive DAT.  Also I save outdated Complement sensitized Coombs Control cells for DAT unknowns.

Mabel,
We used to see this when plasma was thawed but just barely beyond the "slushy" point so that the unit was still very cold when it came out of the waterbath..  You will have cryoprecipitate forming in the refrigerator.  It is sort of like the process where you make cryoprecipitate by thawing the FFP in the cold.

Mabel,
We used to see this when plasma was thawed but just barely beyond the "slushy" point so that the unit was still very cold when it came out of the waterbath..  You will have cryoprecipitate forming in the refrigerator.  It is sort of like the process where you make cryoprecipitate by thawing the FFP in the cold.

Mabel,
We used to see this when plasma was thawed but just barely beyond the "slushy" point so that the unit was still very cold when it came out of the waterbath..  You will have cryoprecipitate forming in the refrigerator.  It is sort of like the process where you make cryoprecipitate by thawing the FFP in the cold.

The latest AABB News is featuring several articles on low iron in blood donors.  The only question I have in light of this is: WHERE HAVE THEY BEEN??  By "they", I mean the AABB, CAP, FDA, and every other agency who regulates our lives in blood banking and supposedly has the best interests of the donors in mind when writing said regulations.  The one truly incomprehensible statement, by Dr. Steve Kleinman, indicates that we haven't proven that iron deficiency is clinically harmful.   By what metric?  How many studies need to be done showing definitive clinical harm?  Anyone who has been iron deficient can testify to definite clinical effects from low iron--once it is diagnosed and they are repleted with supplements.  "Oh, yeah, is this how a person is supposed to feel?  I thought it was normal to be tired all the time, crave ice chips, and have restless legs at night!"
The worst part of this is, to me, that our donors come to us trusting us to have their best interests at heart and assuming we will "do no harm".  Yet the blood center has and always has had an inherent conflict of interest in this matter--they need to collect  blood to meet patient needs, and pressure is (at least until recently) always on to collect more, even though this may mean donors are walking around at least iron depleted, if not outright deficient.  This may be even more the case with younger donors, on which collections centers depend heavily, because, let's face it, they are low hanging fruit.
I have to confess I did not appreciate the scope of the problem until, at my last employer, I started seeing, O neg, male, double RBC donors, who had agreed to do 3 DRBC collections a year, after regularly donating WB every 8 weeks for several years, coming to my attention.  It seems that several (at least a half dozen) were unable to do their usual activities after one or more DRBC donations; one particularly memorable story involved a donor having to be carried off the golf course because he became so short of breath that he could not finish 9 holes, walking, which he had been doing for years.  When they saw a physician, their hgb was generally <10, and in several cases, <9!  All had ferritin levels below 20, which is iron deficient.  And, since all were middle aged men, they were all subjected to colonoscopy, as GI bleeding is the leading cause of low hgb in men this age!  I was put in the position of telling these donors they needed to take their supplements faithfully as well as take a prolonged break from donation.  For this medically sound advice, I was called out by several managers for decreasing the donor base, while I was trying to keep donors safe!
As blood donation is a voluntary activity, we need to be especially cautious of doing no harm.  The STRIDE study (Strategies to reduce iron deficiency in blood donors (STRIDE). Transfusion, 2016; epub prior to print) showed that 60% of donors tested were iron deficient AT BASELINE!!  Several interventions, including thank you letters, letters with ferritin level and advice to take daily iron if ferritin was low, as well as 2 levels of iron supplementation provided by the center, were performed. Surprisingly, the donors receiving the "low ferritin" letters with advice to take supplements for 8 weeks did nearly as well repleting their iron as the donors actually receiving iron pills from the centers. How hard is this?  Yet the story indicates there is reluctance to initiate ferritin testing due to expense!  Gee, what other tests have we done for years with little or no proof of efficacy for their stated purpose?  
I would welcome add'l input and thoughts on this topic; as you can see, it has been bothering me for some time!

What happens South of the equator.  I wonder how that affects flying antisera?

I have to say, all of the questions and answers here are great.  I get calls from my techs who are very fearful of those least incompatible/compatible reactions on crossmatch, even after our reference buddies have detected no underlying alloantibodies. 
I appreciate Malcolm's care in saying "in the right hands".  Competency and proper training is everything.  I fell in love with antibodies/antigens/panels/elution/adsorptions.. 26 years ago as a student.  However, today I (hospital TS) trust and rely heavily on the expertise of our reference family.  Have even delivered chocolates to them once a year.  Thanks for all that you do.

I trust that ALL of the people in charge of the transfusion laboratories in the 50 odd hospitals on our patch at Tooting read your post COTTONBALL, and take good head of the bit I have quoted!!!!!!!!!!!!!!!!!!!

I'd eat the evidence Anna!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Would count as corruption Malcolm!

Can I make some comments about this type of reaction 'from the other side'.  It is easy to forget that reagent red cells come from real donors who have complicated antigens on their red cells.  The donors will be tested for as many antigens as possible, and the presence or absence of those antigens will be noted on the accompanying antigen sheet.  However, it is impossible to test for all those low frequency antigens (LFA) out there.  And unfortunately, antibodies to LFA are often far more 'common' than you would expect.  So, if you're getting an unexplained positive reaction with a reagent red cell it's probably due to an antibody against a LFA.  And the manufacturer is not going to be able to identify it; all they can do is withdraw it from use for the future.  these results are not false positive but unidentified (and probably unidentifiable) positives.  Your reference lab might be able to identify it if they have a good sample from the patient together with a sample of the cell.
As for reagent red cells with positive DATs when used in gel (Frenchie) - you will sometimes see positive reactions in IgG or poly AHG in cards if you put the reagent red cells on to the cards without any plasma, due to the fact that the cells are not meant to be used in that way.  Usually if you repeat with neutral plasma, the 'positive DAT' disappears.  If it doesn't, either there is a real problem with the cell (unlikely) or it has become contaminated in your lab.  And - Frenchie again - I would advise you against diluting 3% cells for use in cards.  You could be creating more problems than you think you are solving.
Another reason that you might see unexplained positives is antibodies to Bg.  As far as I know all manufacturers test their cells with a panel of anti-Bg antisera.  However, we all know how variable Bg can be.  You can test a cell with 20 anti-Bg and maybe only 1 of them is positive; and vice versa someone with a known anti-Bg won't react with all Bg+ cells.  So if you are seeing a fairly high number of unexplained positives, especially in pregnant women, then you shuld suspect Bg.
 

A little late on this subject but I thought I would chime in anyway.  We suffered the same problem as you described a few years and 2 employers ago.  When trying to determine what to do about it we discovered that the nurses were being "required" to document the same information in multiple places.  This made no sense so I worked with a team from the nursing department and we came up with a system that only required the documentation in a single place and did away with the other locations.  An example is that they were being required to document vitals both in the patient's chart and on the transfusion record.  Obviously they were much more in tuned to documenting this info on the chart so we removed it from the transfusion record.  Any inspector who wanted to see the info was shown the chart.  Over the years I have discovered that simplifying a process usually enhanced it.