SRMC BB

Has anyone started working on an IQCP plan? I'm starting to look over the information to write one for the HIV test kit we use in Blood Bank. Lots of IQCP's will have to be written in my lab. I cannot find an example of one that's already written to compare mine with....does anyone have one they are willing to share? Or does anyone have an IQCP development policy Any help/comments appreciated! Natalie

I'd love to get rid of elutions...some of our older doctors have now retired and we haven't had an elution ordered for at least a year. What is the Immune AntiA/AntiB test you are speaking of? MAnufacturer, etc?? Most of time with a positive DAT on cord bloods doctor's go ahead and start the bili lights when we call the result. Occasionally, one dr would order an elution and it would usually be ABO incompatibility.

We (Finally) got our microwave! It has been on order since January and we got it late last month and the rep came and did the install/inservice on October 14. The policies are going through med staff and med exec this month so hopefully we will be allowed to use it...soon!!! I'm going to replicate your validation worksheet Terri!

No....we don't know the father's blood type. Even if we tested who mom said was the dad, we (blood bank) can't be sure that he's the baby daddy... I'd love to get a sample one the baby got a little older, but don't know if the doctor would order or has even told the mom that we couldn't get a type. I didn't realize you were referring me to your quotes....sorry it had been a long day Thanks!!

Macroscopic reading of Anti-B and Rh control. using monoclonal anti-B. Don't have access to another anti-B antisera Baby was born with 102 degree fever; mom had fever and foul smelling amniotic fluid per the nurses; culture obtained from placenta; Blood culture drawn from baby just after delivery As of right now, blood culture is negative on baby. Cord was labeled correctly (only delivery at that time and I was up in OB while nurse was obtaining cord blood sample. We did not get a capillary sample since we did a venipuncture on baby for a blood culture and a CBC. Where can I find Dansket and Mabel's to do lists? I'm not familiar with them.

tube method; Rh control neg

I have a cord blood that is typing as follows: A 4+ B 1+ weak, but it's there D 4+ DAT is negative; mom is O pos. Repeated type on a venipuncture and it repeated the same. I reported unable to type; DAT negative Any suggestions........ TIA, Natalie

Our surgeons are wanting FFP super quick in traumas. We do not keep FFP thawed ahead of time and only use FFP, not thawed plasma for 5 days. We currently have a Helmer DH2 which takes about 30 minutes to thaw 2 units. Does anyone use a microwave plasma thawer? How do you like it? Does it really thaw in about 5 minutes? In reviewing the Joint commission stds Standard QSA.05.14.03 #2 states that the lab thaws frozen plasma between 30 to 37 degrees and protects outlet ports from water contamination. I know we wouldn't have an issue with the microwave and water contaminating the ports, but, does this standard apply to the microwave thawer? If anyone is Joint commission accred. please let me know how you comply with this standard. Thanks, Natalie

We use 1-6 C. The way an AABB surveyor explained it to us (but didn't cite us on it) was the 1-6 C was used if blood left refrigerator to go for transfusion...issued for patient tranfusion. The 1-10 C was if blood left the refrigerator to go to another refrigerator...(transporting blood--if we shipped blood to another hospital) Issuing in a cooler was considered temporary storage and fell under the 1-6 C for acceptable return.

They are monoclonal for ABO antibodies

Any reference besides current technical manual? - - - Updated - - - We are still manual tube testing, no automation here yet

Our cord blood screen procedure, which was in place when I took over as senior tech in blood bank, has always stated to make a 3-5% washed cell suspension to do the ABO/Rh type and then wash cell suspension an additional 8 times before adding reagents for direct coombs and a control. I think this is over kill, since washing it 4 times, then adding reagents results in a negative control. (If the control were positive, then additional washes would be necessary). Our cord bloods are collected by nursing with a needle and syringe and placed into an EDTA purple top tube. The technical manual also states that collecting with a needle and syringe avoids contamination with Wharton's jelly and the need for additional washings. I know the reason behind the "8 washes" was to wash away the Wharton's jelly, but with EDTA tubes, I've not seen any interfering substances. Plus, I cannot find a reference to wash it 8 times, just the tech manual now stating that additional washes are not needed if collected with needle and syringe. So, with all that being said, what does everyone else do? I'd love to change it make a 3-5% cell suspension (no washing needed to do the ABO/Rh type) and then wash the cell suspension 4 times and then add the reagents for the direct coombs and the control. Thanks Natalie

Does your process for SOPs describe how you review SOPs when a new edition of standards is published to ensure you are meeting new/revised standards? Does your SOP for SOPs describe how you check Standards when you write a new SOP to ensure you are meeting current standards? Then, of course, you have to have documentation that the review is performed when a new edition is published.

We did use the form from AABB to submit our responses. Our assessor did not think they were major, and we had already told her what we were doing to correct them and she seemed fine with our responses and didn't indicate any reason that AABB wouldn't accept our plan. I am planning on doing something similiar to what Cliff suggested, going through each standard and referencing it to my prodecures. On standard was that the medical director approve any deviations to policies, etc (std 1.3.2) and it dealt with conditional releases. My policy said to consult medical director. We thought we were following policy when something was a deviation, we got his approval. Didn't look at it as the deviation itself was out of the ordinary and had to get his DOCUMENTED approval. I think the main issue was we were lacking supporting documentation and that's were we are headed with the followup to the corrective action plan. The root causes are the hard part---why? why? and why? Because I'm human and I didn't interpret the standard that way???? Don't know if they will like that answer. We are going to make a form to follow (taken from commendable practices on AABB website) to make sure this doesn't happen again.

We submitted our corrective action plan to the nonconformances cited during our AABB assessment. The assessor didn't act like they were a big deal and we had our plan drafted before the assessment was even over on how to fix the citation. However, we've received a letter back from AABB requesting further information and to do a root cause analysis. (How I hate these!) Anyway, AABB seems to think that since we revised some policies, that there might be an inadequate process to make sure all standards are being addressed in my policies and wants to know why the process used to develop SOPs is failing to asure we meet all standards and no detect failure to confrom to standards. Our practice is in compliance with the standard and a few instances of documentation were missing and we could not prove compliance. Any suggestions on how to handle the root cause, we don't want to sound argumentative, but we do follow the standards. In the corrective action plan, I tried to be precise and brief and now think I might have been too brief in my root cause and this is why we are being asked for more information. Also, How do your facilities make sure each and everyone of the standards are covered in your SOPs? Thanks in advance for any advise! Natalie

Could I see a copy of your graded policy? I think this might work well for us. I will mention the "grading" to our medical director and see if he likes the idea. Hopefully, we could just notify the recipient's MD's and they will handle it since I don't believe there is any reason to alarm the recipients. Thanks!! Natalie My email is nlamb@sampsonrmc.org if you will send the "grading" guidelines to me.

I have it in my policy to notify the recipient. The problem is, the lab manager and Medical director want the reference and the only references I can find relate to look back notification for HCV and HIV. Nothing on Core, HBsAg, HTLV, etc. This is (thankfully) the first time this has come up for us. The AABB standards say to identify the recipients, (7.4.6.2.1) and then notify if appropriate (7.4.6.2.2) and this standard references 21 CFR 610.46-48 and 42 CFR 482.27 ©. Both CFR's deal with HCV and HIV. I don't see why we have to look-back if we don't have to notify them:confused::confused:

We do the confirmatory for HCV. I'm looking for information about HBc (Core). Thanks

We had a donor that was reactive for HBc and was reactive again after the 8 week deferral for HBc reentry. We had indefinetely deferred him from future donations and the donor has been notified. While doing the "Look-back" of recipients, I traced back one year prior to his last nagative donation and found 3 recipients of 4 components. My question is this....are these recipients supposed to be notified? The medical director thinks this may cause more harm than good to notify these recipients since there is no confirmatory test. I can only find in the CFR's where it states to notify those that were HIV & HCV confirmed positive, and no other infectious disease guidelines. And again, I'm wondering what is the point of a look-back when there are no notification guidlelines (except HIV & HCV). Any help and references will be greatly appreciated. Thanks! Natalie

Does anyone have a plan in place for this? I have a plan about the pandemic flu from a few years ago and we have a separate hospital wide Influx of Patient plan. I'm in Blood Bank and the manager gave it to me to include in this plan. Any suggestions? Thanks, Natalie

I'm in the (neverending) process of reviewing the procedure manual for the year. I've never really liked our prewarm procedure as it was written well before my time here. Does anyone have a procedure they are willing to share to help me out. Thanks, Natalie

We stopped putting stickers on units several years ago. Our LIS (Meditech) is set up to automatically order retypes so they do not go to available status until the retype is done. There is no standard that states a stickers has to be on the bag, just that the retype done.

I would also like a copy of the spreadsheet and quiz nlamb@sampsonrmc.org Currently we allow, RNs, LPNs, CNAs, ERTs, and unit secretaries to sign out blood. They must be inserviced. We do not allow students or nursing instructors to sign out and transport blooe.

Does anyone know where I can get transfer packs (to make split units) ? I need a BOX and not a CASE. We don't do that many so we'd waste a bunch if I order a case of 96. The ones I have were received in 1994 and I have several boxes left!! We were told by our assessor to get new ones because these were soooooooooooooo old!! Thanks

We are a small hospital that draws our own donors and we have a transfusion service. Thanks for any input. Natalie