Dr. Pepper

Once in a while we outdate a vial of Rhophylac so I dilute it a bit and give it to the students to do a panel. Panel always shows anti-D+C

Welcome to the pathlab family KaterinaN! Phil

And did they politely thank you Auntie, and grace you with a glacial smile?

I had a routine diagnostic procedure done the other day. A 40-year RN missed my sewer pipe vein trying to start an IV. Later that evening I scratched at some irritation on my chest and found they had left 3 electrode patches on me. Not huge things, but this was done at a local hospital that fancies itself the mecca of medicine in the state, if not the world and universe. We make pretty well-informed patients (thank God); unfortunately, the average patient off the street does not have that advantage.

Malcolm, I trust you didn't have to go clothes shopping at Walmart again......

Malcolm, if you make your jaunts to the US any shorter you'll be turning around over Nova Scotia.

And Immucor says "....the reactivity of the RBC may be checked periodically by testing antigens likely to deteriorate, such as Lea, with weakly reactive antibodies of the same specificity. If such antigens are found nonreactive, the product should not be used." Huh, good idea. What about the antigens that we do care about?. I look at the "may", as opposed to "must" or even "should", as meaning this is entirely up to you.

All this just reinforces my opinion that one should never, never, ever get sick, because then you can get treated and all sorts of bad things can happen!

OK, I bit the bullet and asked CAP: For COM.30450, the intent is to check a new lot and/or shipment of reagents before use in patient testing in order to confirm that proper shipment conditions were followed (to the best of the lab’s ability), and that the new lot of reagents gives the same results that your old lot did. This applies to all reagents, routine and rare. As COM.30450 includes below, external QC materials tested on the previous lot, and compared to the same material tested on the new lot, is acceptable. Reagent cells can be tested against an antibody of known reactivity; again the intent being to be sure the level of reactivity with your new lot is within acceptability to the reactivity of your old lot. Question: What does my laboratory need to do to QC antibody panel cells when they are received? Answer: Antibody panel cells are considered critical materials in a transfusion service. Laboratories must follow the requirements in TRM.312441 stating, “New lots of reagents and critical materials are inspected and tested, as applicable, before use, with documentation of acceptance”. The inspection of the reagent involves a visual assessment to check for hemolysis or signs of contamination. The findings must be documented on a inventory log or other quality control record. Quality control of a new antibody panel presents a challenge because it is not feasible to check the reactivity of each antigen on each panel cell. In addition, antibody panels have a short expiration date and many laboratories order multiple panels to ensure that they have sufficient selected cells available for ruling out antibodies. An antibody panel is an investigational tool used to identify the specificity of red cell antibodies and is never used alone when interpreting the results. In addition, laboratories follow defined rules for confirming or ruling out antibodies on the panel, including comparing the results from the panel with the patient’s antigen typing for the antigen of interest, the antibody screening results, patient history, and additional special studies when indicated. For quality control, the laboratory must follow procedures for interpreting the results and follow the manufacturer’s instructions for quality control, at minimum. While not ideal, the laboratory may also use the following processes to check the reactivity of the panel cells: - Confirm the reactivity of one or more panel cell using a reagent antisera or a dilute antibody - Select a known positive and known negative panel cell as the controls when performing an antigen typing - Run a panel with a known antibody prior to use - Since the red cell panel is an investigational tool to identify the specificity of red cell antibodies, labs can show that when they confirm the patient for the corresponding antigen and select a known positive and known negative panel cell as the controls, if the positive and negative cells react as they should, the lab would be satisfying this requirement. I hope this helps.

I'm SO glad we don't have one of these. OK: chart/alarm shows temp stayed within range, temp was recorded once during the day. Keep the blood. Not OK: chart/alarm shows temp stayed within range, temp was not recorded once during the day. Throw away the blood. I kind of like Dave's point "Better to eat them and use the incident as a means for better compliance with regulations." However, I don't see a difference in how the blood was stored in the 2 scenarios, aside from a note on a logsheet, so I side with goodchild and kirkaw. The real issue, as Dave continued, is that the units could have been taken out of the fridge, sat and cooked for half a day on a counter, then put back in. In either scenario you wouldn't know it. There's my non-answer. Throw them away if you want to make a point to the OR, but I see no difference in safety whether someone recorded a random temp or not.

For decades we hired only MTs, but have had to hire a few MLTs over the last couple of years due to MT shortages. I find the quality of work varies not from the number of college courses they took but the innate ability, initiative and interest of the worker. We train equally and job responsibilities are equal (although the MTLs cannot do some things, like review results etc). I had a MLT generalist on last weekend. He had a patient who got 4 units of blood the week before who now presented with anti-c and a positive DAT, weak mixed field. Pretty classic delayed reaction, except that the eluate reacted with all the panel cells. DAT was negative the week before. He dug into it and tested some more c-negative cells and found that there was also anti-Fya and -Jkb in the eluate (but not in the plasma yet). En route he tested the eluate with ficin-treated cells and PeG and ficin-treated some additional ones himself to help untangle the specificities. I did give him some phone coaching along the way, but it was an excellent job of blood banking. "Just" a MLT, but he really digs BB.

Ditto to all the above. You did a fine job. A few thoughts: 1. Your BB should have some procedures regarding "what if" situations (uncrossmatched blood, uncrossmatched blood with antibodies, etc). An emegergency release form with several check boxes for different scenatios is helpful; there was a thread a few months ago where someone had added the relative risks of hemolytic reactions under those scenarios. If you don't have those in place, and you've got a decent relationship with your supervisor, you could gently suggest that they could be very helpful to a newbie (as well as everyone else). 2. Practice your emergency issue scenarios. The Boston Mathathon bombing victims did very well because the hospitals treating them had active trauma units and held frequent drills. 3. Someone should always be available to give a helping hand, for both benchwork or advice. 4. Someone exsanguinating bleeds out their antibodies, too. Your patient may have a delayed reaction down the road but at least they'll be alive to do so! Worst I had it was years ago with a ruptured AAA who had anti-K. The anti-K antiserum used an indirect AHG test in those days, so there was a time constraint. My coworker and I kept ahead for about 25 units, then ran out of screened, crossmatched blood. The OR called and said if we don't get 10 units RIGHT NOW the patient will die. So we grabbed 10 units, stuck a segment from each onto the counter with a bag sticker, tossed them in a pile on the dumbwaiter and sent it up a floor to the OR. And did this again. We eventually caught up, and the patient did indeed die, but not from a reaction or lack of blood.

Malcolm, I hope you're not too sad that you're on holiday.........

Me too, the first time. Now I just sigh and call myself a bleeping idiot.

Hmmm, there is a mechanism, the same one by which a 4-channel lab timer might end up in your kitchen.....

Same as Rita - been using the Immucor product in tube for years. This has been a CAP requirement for a while now.

It's not exactly a lab issue, but have you ever dialed a phone number on your computer keyboard (or desk calculator) instead?

Thank you Mari. Regarding #47, it is first on my list of blood bank skills that will be useless in my retirement (coming within the year I might add): being able to reach into a sleeve of 12 x 75 tubes and grabbing exactly 12 more times than not (and also knowing you've got one too many or too few). Phil

I agree with Terri. For years, AABB indirectly endorsed the 30 minute rule in the Tech Manual with a passage that read something like "Many facilities use a 30 minute limit....." but they dropped that a few editions ago and now want you to take the unit's temp. The 30 minute rule has to date back from the whole blood bloated bag days; if you try this yourself with a mock or outdated unit of packed cells you'll find it's more of a 15 minute rule at best. An inspection or two ago, I asked about the no-win situation with FFP, and they basically said you're screwed, it has to come back <10o, which is rather tough when you issue it straight from the waterbath.

Malcolm, don't feel too embarassed, if we were in London we would probably be mailing our post cards in ash trays.

We have had a few incients such as Terri's. A point you might make is that it doesn't have to be a blood bank specimen to have a bad outcome. The wrong person's coag, CBC, glucose, potassium or culture can kill you just as dead - and there's a heck of a lot more of them coming into the lab. Do you have any misidentified statistics to share, and try to improve? You can stress that they're also just the tip of an unknown iceberg. We only find the ones whose type has "changed" or who fail delta checks. LABEL AT BEDSIDE! Good luck.

There was a blurry photo on a wanted poster at the post office this weekend. Something about fire, rugby hooligans and the US mail...........

All may not be lost. One of our seminar speakers last week did a talk on FFP which included some data on stability of FFP stored for various times/temps out of range. I'll see if I can get the references from her.

Malcolm, the pleasure was ours. I will share one story of our experiences. It took a while to spring Malcolm from the clutches of Logan airport, what with his flight being delayed, a crowd at customs, and the lost luggage. We finally made it back to RI, and I opened a nice bottle of Sonoma zinfandel. We clicked our glasses together in a "Welcome to RI" toast, and my wife slopped hers onto the front of Malcolm's shirt. Malcolm was very gracious about the purple blotch on his one and only shirt, and we braved the Walmartians the next morning to do a little shopping.....

AABB 5.11.2.1: "The completed label shall be affixed to the tube before the person who drew the sample leaves the side of the patient." CAP TRM.40230: "All blood samples for compatibility testing are labeled at the time of specimen collection in the presence of the patient with..." And as Malcolm says, even if it weren't against the standards, it's a very bad idea. So you need to: 1. Have your phlebotomy procedure state the above (nursing, lab, docs, phleb team, whoever draws specimens). 2. Have your blood bank P&P say you won't accept specs that aren't labeled as above (like the bags). 3. Why not put it into your hospital's transfusion policies as well, approved by the medical staff. Then you can always point to it and say "It's not just us picky SOBs in the lab who say that, it's Hospital Policy". (You don't have to tell them that you wrote it.) I have to say our lab will accept some specs "in the bag" but only very specific ones (timed blood draws like drug peaks, surgical specimens) that cannot be reobtained. Someone signs an affidavit.