Dr. Pepper

Wow, can't remember the last time I read a 4 page thread from start to finish! 
 
Txlabguy82 this is definitely one of those "s....tuff happens" occasions.   Personally I see nothing in your process that would concern me,  Actually there is a fair amount to commend you for.  As far as this possibly being a sample problem, I think not.  I've used short sample EDTA tubes far more often than I care to admit.  I guess, just to join in on the questions, could the sample have agglutinated as opposed to clotted?  Just a random thought and not real sure where it's going but it did come to mind as I was reading. 
When I was supervising blood banks and transfusion services I never got overly excited about the random one time occurrences, especially those where no real cause could be pin pointed.  The corporate Transfusion QA group hated it when I would remind them that as long as humans were involved in a process there would be the occasional human error.  Now, whether or not this particular case was human error will probably never be determined.  Bottom line; the patient received her dose of RhIG because the process discovered a problem.  Why the problem occurred will, most likely never be truly determined so don't let this eat at you over much.  My recommendation, find employment as a dedicated bloodbanker and enjoy the rest of you career. 

Goodchild, you hardened cynic - why that would be the one long, long ago, in a galaxy far, far away, where they don't thumb through the chart while the patient is getting prepped and say "Holy bleep! His INR's 7, his platelets are 6, his hemoglobin's 5, his glucose is 4........."
 
Hey, I said that was the point, not that anyone did anything about it. But I LOLed too.

Makes sense Mabel, and could explain the jump in reactivity from 1+w (IS) to 3+ (IAT), although that seems to be a pretty big jump. I had been considering a bit of D+ RBC from a different patient in the RBC suspension but I think txlalabguy82 only does one patient at a time.
And txlalabguy, please don't hate blood bank! I think you need to compartmentalize all the issues running around in there (I do know that can be hard) and just concentrate on the job at hand. Blood bank, chemistry, UA, heme, it's no different - keep focused on what you're immediately doing, and let the other guys out of the boxes when it's time for them.

A few thoughts (always a dangerous thing when it happens to me):
- You could put Malcolm's theory to the test and try repeating the testing with reagents and, for that matter, the patient specimen, straight from the fridge.
- If Anna's theory about 2 cell populations is correct, why weren't the reactions repeatable when retested several hours later? The baby's cells should have still been there.
- Speaking of 2 cell populations, was another D+ patient being tested at the same time? Could some of his cells have gotten into the RBC suspension that was mostly D-? Years ago we had three patients in a row who had positive antibody screens. They all had anti-D. They were all D- but the auto controls were all positive. The tech had aliquotted the sera off of three clots sitting side by side into second tubes in the rack for the testing, then added her typing reagents to the testing tubes. Trouble was, she apparently added a drop of anti-D to each of the three serum aliquot tubes instead of the tubes for the anti-D testing! Point is, maybe here the wrong stuff got in the wrong tubes. 
- The initial testing sure looks like a weak D though.
 
Who really killed the Kennedys? Sometimes we will never know the answers. I'll stop thinking for now.

In 30 years had exactly one case of mislabeling from our local blood supplier. It was an autologous unit and they used to write in the ABO/Rh by hand. Someone put A Neg on instead of A Pos. Shortly after they switched to computer-generated labels.

And you said, Sure, pull up a chair!

Goodchild, you hardened cynic - why that would be the one long, long ago, in a galaxy far, far away, where they don't thumb through the chart while the patient is getting prepped and say "Holy bleep! His INR's 7, his platelets are 6, his hemoglobin's 5, his glucose is 4........."
 
Hey, I said that was the point, not that anyone did anything about it. But I LOLed too.

In what world do surgeons/anesthesia review charts prior to the surgery?

Another issue with shortening the preop window is that, although we do sometimes have departmental tunnel vision, there are other lab tests to be performed and acted upon besides pretransfusion testing. The whole point of getting the blood work done many days ahead of time is to get the abnormal glucose, creatinine, H&H, coag etc. sorted out before the day of surgery - not just antibody problems. So there would be less time to deal with these potential problems as well.

Another issue with shortening the preop window is that, although we do sometimes have departmental tunnel vision, there are other lab tests to be performed and acted upon besides pretransfusion testing. The whole point of getting the blood work done many days ahead of time is to get the abnormal glucose, creatinine, H&H, coag etc. sorted out before the day of surgery - not just antibody problems. So there would be less time to deal with these potential problems as well.

The kind of people who tried to "write up" Scott and David should have their crayons taken away until they can learn to play nicely!...or, to put it another way, they should have their ability to try to ruin others' professional lives taken away until they actually have a clue about what they are talking - which, in the case of most such people, is a life sentence!
 
       

I digress, but in response to David's post, I had a resident bring a specimen for culture to the Microbiology department, where I was working part-time as a student, and he asked if he should wait for the results.

We once received a letter that the patient said "was VERY important" if he ever needed transfusions.  We had to call our interpreter service because the letter was all in German

"I told him that such an action violates every regulatory, legal, ethical and moral standard I can think of, especially since the original results cannot be proven to have been wrong and it sounds like it was an attempt to avoid admitting a mistake either in collection, labeling or testing."
AGREE, AGREE, AGREE! And with Goodchild. From time to time we encounter historical typing discrepancies like this. We determine the actual type, as Goodchild, with two samples. Then we see if there's a technical reason (weak D, BMT, change of reagent/methodology - we use tube and our affiliate uses gel). Then try to figure out what happened, sometimes impossible because it always seems that the old result from 6 months ago was the bogus one. Besides Goodchild's scenario it could have been WBIT, identity borrowing or theft, or a mixup in samples in the lab (I've seen all of these). Document, correct old reports, incident report, and correction in the LIS BB history (when you're very sure of the true ABO/Rh).

"I told him that such an action violates every regulatory, legal, ethical and moral standard I can think of, especially since the original results cannot be proven to have been wrong and it sounds like it was an attempt to avoid admitting a mistake either in collection, labeling or testing."
AGREE, AGREE, AGREE! And with Goodchild. From time to time we encounter historical typing discrepancies like this. We determine the actual type, as Goodchild, with two samples. Then we see if there's a technical reason (weak D, BMT, change of reagent/methodology - we use tube and our affiliate uses gel). Then try to figure out what happened, sometimes impossible because it always seems that the old result from 6 months ago was the bogus one. Besides Goodchild's scenario it could have been WBIT, identity borrowing or theft, or a mixup in samples in the lab (I've seen all of these). Document, correct old reports, incident report, and correction in the LIS BB history (when you're very sure of the true ABO/Rh).

"I told him that such an action violates every regulatory, legal, ethical and moral standard I can think of, especially since the original results cannot be proven to have been wrong and it sounds like it was an attempt to avoid admitting a mistake either in collection, labeling or testing."
AGREE, AGREE, AGREE! And with Goodchild. From time to time we encounter historical typing discrepancies like this. We determine the actual type, as Goodchild, with two samples. Then we see if there's a technical reason (weak D, BMT, change of reagent/methodology - we use tube and our affiliate uses gel). Then try to figure out what happened, sometimes impossible because it always seems that the old result from 6 months ago was the bogus one. Besides Goodchild's scenario it could have been WBIT, identity borrowing or theft, or a mixup in samples in the lab (I've seen all of these). Document, correct old reports, incident report, and correction in the LIS BB history (when you're very sure of the true ABO/Rh).

funny how that stuff occurs. I got written up once for not providing blood culture reports 1/2hr after the specimen was collected . . . The Medical Director provided some direction to the intern. (I reported "no growth upon plating")

In 30 years had exactly one case of mislabeling from our local blood supplier. It was an autologous unit and they used to write in the ABO/Rh by hand. Someone put A Neg on instead of A Pos. Shortly after they switched to computer-generated labels.

We tried these years ago with limited success - our own patients wouldn't show them to nursing/MDs. A few years ago I did get a call from a patient in her late 80s who had received her card in the 1970s, and, 40 years later, presented it when she went to a neighboring hospital, who never gave it back! We got her a new card and wished her well. Her antibody, by the way, was no longer detectable, so I guess our old program was not a total failure. Anna is correct about the patient education piece. And I liked the letter a lot, but I question whether the patient's doctor is the best person to give the info to. Our cards (we are trying this again) read "Should you require transfusions in the future, it is important to forward this information to the blood bank at your hospital."
You can get card stock and a template from Avery (#5871) and make the cards from any printer.

A few thoughts (always a dangerous thing when it happens to me):
- You could put Malcolm's theory to the test and try repeating the testing with reagents and, for that matter, the patient specimen, straight from the fridge.
- If Anna's theory about 2 cell populations is correct, why weren't the reactions repeatable when retested several hours later? The baby's cells should have still been there.
- Speaking of 2 cell populations, was another D+ patient being tested at the same time? Could some of his cells have gotten into the RBC suspension that was mostly D-? Years ago we had three patients in a row who had positive antibody screens. They all had anti-D. They were all D- but the auto controls were all positive. The tech had aliquotted the sera off of three clots sitting side by side into second tubes in the rack for the testing, then added her typing reagents to the testing tubes. Trouble was, she apparently added a drop of anti-D to each of the three serum aliquot tubes instead of the tubes for the anti-D testing! Point is, maybe here the wrong stuff got in the wrong tubes. 
- The initial testing sure looks like a weak D though.
 
Who really killed the Kennedys? Sometimes we will never know the answers. I'll stop thinking for now.

Back in the days of serum-only blood banking, if we had to send EDTA specimens to the reference lab they would defibrinate them because I think EDTA tubes can eventually clot after being stored several days.  I don't think that you would get a clot mixed up with agglutination when reading.  They look rather different.  I don't think clots would get stronger in the IAT D test, especially after all of that washing.  Fibrinogen levels rise a lot in pregnancy so her specimen might be more prone to clotting on storage.  I don't know how early in pregnancy that happens and she was awfully early.
 
Quotient's anti-D blend (Alba) has that tendency to react with the i/I moiety.  We see it only on cord samples, probably because there is more i available.  When we find one that is weakly positive at IS and take it through IAT, it goes to negative.
 
Baby cells are bigger but less dense (more retics) so they rise to the top of a spun sample just like in the reticulocyte separation technique.
 
I vote for something getting into that tube with the anti-D that you didn't intend.  It could even have got in there before you touched it.  Let's say someone got out tubes to do some testing but later changed their mind and put them back.  While they were out they got a splash of a group O or A patient's plasma in the one that you later chose for your D typing tube.  Now that tube had a bit of anti-B in it plus the anti-D that you added.  The anti-B would react with the patient's B neg cells and look like a weakly positive D type.  Because you put the same tubes in to incubate for the IAT D typing, this carried over. Because it was a patient's sample it could even have some IgG anti-B in it that could react better at AHG.  I have a long habit of starting with new drops of cells and antisera in new tubes when I do a weak D test--that way I can make absolutely sure that I really put anti-D in the tube in case that is why the IS D type was negative.  Another possible idea would be that a splash from your reagent anti-B got in the D tube.  You'd have to test whether that would get stronger at AHG since it likely contains no IgG anti-B.

We had been using an arbitrary 14 days if not pregnant or transfused, but recently expanded to 21 days or the OR's request - too many redraws. I think the only limit is your own comfort zone and storage space for specimens for serologic crossmatches and/or keeping them for a week post-transfusion.
 
If you perform serologic crossmatches and transfer your serum/plasma to an aliquot tube while doing your T&S, I have noticed that once in a while there will be a turbid layer of microbial growth in the aliquot tube after several days' storage.
 
Our LIS electronic crossmatch requires an antibody screen within 72 hours but this can be overridden.

We tried these years ago with limited success - our own patients wouldn't show them to nursing/MDs. A few years ago I did get a call from a patient in her late 80s who had received her card in the 1970s, and, 40 years later, presented it when she went to a neighboring hospital, who never gave it back! We got her a new card and wished her well. Her antibody, by the way, was no longer detectable, so I guess our old program was not a total failure. Anna is correct about the patient education piece. And I liked the letter a lot, but I question whether the patient's doctor is the best person to give the info to. Our cards (we are trying this again) read "Should you require transfusions in the future, it is important to forward this information to the blood bank at your hospital."
You can get card stock and a template from Avery (#5871) and make the cards from any printer.

We tried these years ago with limited success - our own patients wouldn't show them to nursing/MDs. A few years ago I did get a call from a patient in her late 80s who had received her card in the 1970s, and, 40 years later, presented it when she went to a neighboring hospital, who never gave it back! We got her a new card and wished her well. Her antibody, by the way, was no longer detectable, so I guess our old program was not a total failure. Anna is correct about the patient education piece. And I liked the letter a lot, but I question whether the patient's doctor is the best person to give the info to. Our cards (we are trying this again) read "Should you require transfusions in the future, it is important to forward this information to the blood bank at your hospital."
You can get card stock and a template from Avery (#5871) and make the cards from any printer.

We had one once that was sent in to us because it was getting a bit battered and bruised, and the lady wanted a new one.  The original was signed by a certain Dr Ruth Sanger!!!!!!!!!!!!!!!!!!!