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Posts posted by blut
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Hi all,
I'm hoping that UK colleagues involved in NEQAS can help with the following issue:
Background: I've corresponded with a colleague in Switzerland to explain why transfusion services in Canada and the USA rely on gel-IAT to detect unexpected antibodies and do NOT do an extra enyme-IAT gel antibody screen, as her hospital does, to detect possible antibodies in the Kidd system that may be too weak to be detected by gel-IAT without enzyme-treated red cells (summary of reasons below).
My colleague offers this evidence for why her hospital's transfusion service lab includes enzyme testing:
"The UK NEQAS report published in Transfusion Medecine 2002; 12:11-23 states that sample 988RO Anti-Jk(a)Detection rate by technology* LISS tube, NO (%) 143 (89)* Diamed (Geltest) 34 (19,3)"From the cited statistics, if 0.89n=143, LISS n=160.7 and if 0.193n=34, Gel n=~176 (where n=no. of labs performing each method).
My questions:
1. Has Diamed gel consistently performed that poorly for Jka compared to LISS methods?
2. If yes, it it possible that human and systemic error involved in the Diamed test played a role in this particular survey, now ~10 yrs old/ (e.g., wrong LISS diluent, wrong pipetting technique)
3. My sense is that labs in Europe use enzyme-treated rbc in gel (and possible other) testing more than in NA, where enzymes are not used for routine antibody screening but reserved for more complex antibody identification. Is this true for the UK, and if so, what are the rationales?
4. Did NEQAS or influential professionals suggest that the cited study provides a valid rationale for including enzyme-IATs when antibody screening by gel?
Thanks for any comments you can offer.
Cheers, Pat
TraQ: http://www.traqprogram.ca
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SUMMARY (omitting enzymes in routine antibody screening):
Kidd antibodies are relatively rare and ones too weak to be detected by LISS-IAT, Gel-IAT, PEG-IAT, etc., are rarer still. Today most NA labs rationalize testing so as to stay within constrained budgets.
For example, papers on test rationalization by John Judd and colleagues on
(i) why doing a routine autocontrol (~DAT) when antibody screening is not cost effective:
http://www.ncbi.nlm.nih.gov/pubmed/3705135
(ii) why reading antibody screen tests at 37C (applicable only to standard saline and LISS tube tests) is not effective:
http://www.ncbi.nlm.nih.gov/pubmed/10204593
Similar arguments can be made for not adding an enz-IAT just in case gel-IAT or LISS-IAT alone do not detect weak Kidd antibodies.
The clinical significance of weak antibodies missed by IAT testing by any method using anti-IgG (e.g., LISS, PEG, gel) is open to question.
Nancy Heddle, for example, showed that most delayed hemolytic transfusion reactions were actually "delayed serological transfusion reactions". Antibodies detected 5-7 days post-transfusion hardly ever caused clinical symptoms in the patient (only one in her large study):
http://www.ncbi.nlm.nih.gov/pubmed/8547111
The risk of missing a weak anti-Jka that needs enzymes to be detected is small. Even when missed, how much red cell destruction the antibody would cause is debatable. Enzymes detect many clinically insigniifciant antibodies. Eliminating enzyme tests has a low risk and significant benefits.
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Everyone...please re-read post #1 and #4. This IS NOT a hiring issue but the posters have morphed it that way. There are a lot of "ifs" and "assumptions" being made. Admonishments and points taken...
Sorry about the mistaken hiring focus, KBBB. I should have read more closely. After a re-read, the tech in question apparently already works at your facility and the issue involves whether the person should be trained for the transfusion service.
Some of the same precautions still apply (anecdotal evidence, what actually contributed to any error that may have occurred, role of training & competency assessment, and fairness).
Without the details it's hard to comment further. I'd just reinforce that serious errors are often due to systemic problems. Also that nothing beats open, respectful communication.
Based on my experience, it's odd that anyone involved in making a life-threatening error would want to go anywhere near the blood bank.
Cheers, Pat
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A few comments....Seems that there are several related and competing issues:
1. Privacy rights of the job applicant
2. Reluctance to hire a person whose job performance, based on anecdotal past history, may jeopardize patient safety
3. Reluctance to hire a person whose past job performance, based on based on anecdotal evidence, may have been sub-standard
4. Fairness in hiring practices
Privacy rights are covered by applicable legislation. In Canada, for example, there is the Freedom of Information and Protection of Privacy Act (FOIP):
Although Canadian, the explanation covers the main privacy issues involved when hiring someone regardless of location.
Regarding #2 and #3 above, as others have mentioned, it's never a good idea to base hiring practices on unsubstantiated anecdotes.
About patient safety and inadequate performance, this is often about systems that fail (not necessarily people) or training issues. Anyone can make mistakes, even big ones with dire consequences. With life-threatening errors, root cause analysis is needed to identify what reallly went wrong.
It's been my experience over a lifetime that we in the transfusion service often get away with our errors through happenchance.
Bottom line: If it's not a character issue (e.g., person is inherently lazy and inattentive), then proper training and competency assessment should correct deficiencies.
Regardless, to me the key issue is fairrness. Put yourself in the applicant's shoes and decide how you would want to be treated.
Cheers, Pat
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Hi Meg123,
Websites that may be helpful:
1. Blood bank modules:
http://www.ualberta.ca/~pletendr/tm-modules/
Caution: I developed these modules many years ago when I taught blood banking and have not kept them up. They are very basic, do not include the latest advances and methods, use frames (no longer used on the web) and some external links may be broken. Nonetheless, I think the modules are still relevant for learning basic theory and test practices.
2. TraQ case studies:
http://www.traqprogram.ca/CaseStudies.asp
Level B cases are the most relevant for basic problem solving.
3. Canadian Blood Services educational website:
http://www.transfusionmedicine.ca/resources/books/vein-vein
(copy & paste to the end of 'vein-vein')
See the links beneath the video, particularly Pretransfusion and Complications .
All of the above resources are freely available.
Cheers, Pat
UA: http://www.ualberta.ca/~pletendr/
June's TM blog:
"I will remember you" (Musing on mentorship")
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Thanks, Malcolm. Can I assume that NHSBT acts as a reference lab for hospital transfusion services and it is typically only antibody identitification and other complex testing they pay for? Or does NHSBT perform all pretransfusion testing for some small labs that act as dispensaries of blood (no on-site testing)?
For interest, in Canada Canadian Blood Services (CBS) performs such testing free of charge to the user. However, most smaller facilites are part of a health region and use their region's central transfusion service laboratory as their reference lab. Also, often it is the central transfusion service that receives blood from CBS and then distributes it to smaller labs, which may or may not do basic or complex pretransfusion testing.
As an aside, I loved your "Lax Terminology" article in April's Bloodlines and CPD News. What a good publication.
Cheers, Pat
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Malcolm,
In NHSBT who is charged for testing? Who do they pay and how? Is there a public doc that explains the process? Thanks.
Cheers, Pat
UA: http://www.ualberta.ca/~pletendr/
TraQ: http://www.traqprogram.ca/whatsnew-chrono.asp
TM Blog: http://traq.blogspot.com/
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Hi all.
I write a blog titled "Musings on Transfusion Medicine" and the latest entry may interest some on BB Talk:
"Don't ask, don't tell... Time to fold 'em or bad moon rising?" (Musings on the MSM deferral policy for blood donors)
The blog entry is about a court case involving Canada's national blood supplier and regulatory body (CBS and Health Canada), and a *** blood donor who lied repeatedly on his blood donor screening questionnaire:
Please feel free to add comments directly to the blog, either anonymously or attributed.
Cheers, Pat
UA: http://www.ualberta.ca/~pletendr/
Romantic Life of Toast: http://www.palwrite.com/
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The TraQ website has many checklists in its Competency Companion manual. They are hsitorical (have not been updated for years) but you may still find them useful:
http://www.traqprogram.ca/cc.asp
Cheers, Pat
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First, you use varied approaches to stimulate interest and the mere fact you're asking suggests that you are already an accomplished and successful instructor. I've found that it's mainly the good ones who are interested in getting better.
These tips may be 'old hat' but over many years of teaching they have been successful. About powerpoint presentations (PPT), I agree with Rashmi and would add these observations and practical tidbits:
1. Unfortunately, participatory activities take more time than force feeding information. Instructors always have to balance available time with "covering the material", usually at the expense of interactivity and learner participation.
Think of ways to maximize the quality of F2F time. If it's straightforward info, put it in a pre-session handout, ask if there are questions, and later require them to recall and demonstrate the knowledge via short quizzes or case studies.
2. Remember that PPT is a tool meant to supplement a presentation or seminar, not to replace it and become the whole darn thing. Think of what PPT does best - what it does that's unique and would not normally occur in a lecture or group discussion. To me that's the use of informative and interesting graphics and photos drawn from worldwide sources, including videos.
3. I've tried experimenting with giving entire PPT presentations using mainly graphics with almost no bulletted text. It keeps the audience awake focused on what you say and ask them.
4. Use lots of blanks in the PPT handouts that participants must fill in. Without activity most become comatose in ~15 mins. or start to fantasize about ___ (fill in the blank).
5. Try having the audience complete mini-quizzes at logical section breaks. If required for competency assessment, there can still be an open or closed book quiz at the end.
Toss in some fun bonus questions, like a series of photos to identify football stars (e.g., Wayne Rooney, Cristiano Ronaldo, Fernando Torres, et al.) I doctor photos of real transfusion service staff, donors, patients with the heads of these guys - the pics always get a good chuckle.
6. Those not keen to respond usually belong to one of several camps. In my view, mainly it's because they are adult learners with well developed self-images about their competence, experience and expertise and do not want to threaten that by answering inappropriately and seeming stupid.
I tell colleagues that "Anytime you ask or answer a question you risk saying something dumb." Then give them this quote: "To avoid criticism do nothing, say nothing, be nothing." (Elbert Hubbard) It's pretty harsh but makes the point. To use an analogy, growing old may be awful but the alternative is worse.
Other possible drivers of a reluctance to participate include
* Boredom - discussion questions are (or seem) too easy and obvious
* Material seems irrelevant; perhaps it's not "just in time" or not perceived as essential to their jobs.
* Information overload
* Audience is exhausted and unable to focus.
* Someone is dominating the discussion and turning off colleagues
7. About stupid questions, try this quote (edited), supposedly from Confucius: "They who ask questions may seem to be fools for a moment. They who never ask questions are fools forever."
It helps to model and explain that it is okay to admit not knowing. The instructor sets the tone and atmosphere. See, for example, "I don't know": the three most important words in education from the British Medical Journal (8 May, 1999).
8. To encourage colleagues to respond and draw on their knowledge and expertise, make questions as non-threatening as possible, i.e., open-ended with no clear right or wrong answer that participants can discuss by drawing on their first-hand experiences, e.g.,
* Don't ask, "What's the matter with using patient records alone to determine a patient's ABO and Rh group for purposes of RBC or plasma transfusion?"
Ask, "What's the weirdest (most striking) case you ever saw of patient records being inconsistent with current testing and what was the cause?"
Mine was a young woman admitted for a therapeutic abortion under the complete identity of a married friend, who just happened to be in our records due to a prior transfusion.
Giving questions an experience-based context also increases interest, because most people like talking about themselves best.
Anyway, some food for thought.
Cheers, Pat
UA: http://www.ualberta.ca/~pletendr/
TraQ: http://www.traqprogram.ca/whatsnew-chrono.asp
TM blog: http://traq.blogspot.com/
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Thanks, Lara,
Appreciate the feedback. Let me know how I can improve the cases.
Cheers, Pat
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Thanks, Rashmi,
The cases are fun to do and it's great to learn that they are of use to you guys across the pond.
Cheers, Pat
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The revised TraQ website has a new resource for nurses:
http://www.traqprogram.ca/nurses.asp
Cheers, Pat
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The Musings on Transfusion Medicine blog has several new entries:
1. "Let's get together and feel all right" (Musings on websites that share)
2. "I'm the decider" & the doctrine of preemptive strikes (musings on being a decider, the quality of information, and applying the precautionary principle)
3. Responsibility - what's that? (musings on responsibility for inappropriate transfusions)
Cheers, Pat
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There is a new TraQ case study online:
The case of the disappearing antibody
http://www.traqprogram.ca/Cases-B/Case-B7/case-B7.asp
Cheers, Pat
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Hi, all,
For interest, here are 2 blogs that I wrote for TraQ on the UK manslaughter case. The case involves a group O patient who was mistyped as AB, received group A red cells, and died from multi-organ failure:
Manslaughter case against UK lab worker collapses
Manslaughter charged following wrong blood fatality in UK
The blogs discuss some of the issues in the case and have links to news reports. Feel free to add your comments. Thanks!
Cheers, Pat
TraQ: http://www.traqprogram.ca/
UA: http://www.ualberta.ca/~pletendr/
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Hi, all,
New case study on TraQ:
Case O3 - Method validation in the transfusion service
www.traqprogram.ca/Cases-O/Case-O3/Case-O3-notice.asp
Case O3 is still in the review stage and visitors are welcome to contribute additional validation tools and resources.
Cheers, Pat
__________________
Teaching: http://www.ualberta.ca/~pletendr
TraQ: http://www.traqprogram.ca
TraQ http://blog: traq.blogspot.com
TSO: http://www.transfusionsafety.ca
CSTM: http://www.transfusion.ca
Consulting: http://www.patletendre.com
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TraQ's June newsletter is now available.
June focuses on the usual eclectic international news, a spate of disease-related news items, and a provocative article in which Richard Smith (former editor of the Br Med J) argues that journals are part of the marketing arm of pharmaceutical companies.
I encourage everyone to use Google on our homepage to search the TraQ website. It really is the best way to find our resources.
As June 14 is World Blood Donor Day, check what your country is doing to celebrate (International News).
We are sorry to report the death of Dr. Jack Bowman, a transfusion medicine pioneer and one of the world's leading experts in treating and preventing hemolytic disease of the newborn. See In Memoriam. Your feedback and comments are most welcome.
Cheers, Pat
TraQ: http://www.traqprogram.ca/
TraQ blog: http://traq.blogspot.com/
Teaching: http://www.ualberta.ca/~pletendr/
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Hi, Tim,
Information on World Blood Donor Day in all countries can be found on TraQ under "International News":
http://www.traqprogram.ca/whatsnew-biweekly.asp#news
Cheers, Pat
TraQ: http://www.traqprogram.ca/
TraQ blog: http://traq.blogspot.com/
Teaching: http://www.ualberta.ca/~pletendr/
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Hi, all,
Case A8 (Severe hemolytic transfusion reaction Involving a student) is
now available on the TraQ website:
http://www.traqprogram.ca/cases-A/Case-A8-notice.asp
A-8 is a case in which a student technologist made a technical error that
was not detected by the supervising technologist and the resulting
hemolytic transfusion reaction resulted in patient death. It's a true case,
but as in other TraQ cases, information has been changed to maintain
confidentiality of those involved and to give the case more educational value.
To access the real case:
http://www.traqprogram.ca/cases-A/LevelA.asp
Cheers, Pat
TraQ: http://www.traqprogram.ca/
Teaching: http://www.ualberta.ca/~pletendr/
Consulting: http://www.patletendre.com/
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Elizabeth - Wow! Please tell us you are kidding...
The pathologist is dangerously out of touch with reality. As you say, he has no understanding of the complexities. Moreover, from a risk management perspective, your facility's legal counsel would nix it in a second!
Both CAP and AABB require that the laboratory information system has been validated for blood banking/transfusion medicine activities.
Some resources:
1. FDA - General principles of software validation (Jan. 2002)
http://www.fda.gov/cdrh/comp/guidance/938.html
2. ISBT Guidelines for Validation and Maintaining the Validation State of Automated Systems in Blood Banking (2003) -just to show it's worldwide:
http://www.isbt-web.org/guidelines.pdf
3. For what's required and standard functionality, see CAP Today's 2004 review of blood bank information systems:
http://www.cap.org/apps/docs/cap_today/surveys/1004_BloodBankSvy.pdf
Cheers, Pat
TraQ: http://www.traqprogram.ca/
Teaching: http://www.ualberta.ca/~pletendr/
Consulting: http://www.patletendre.com/
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Hi, Cliff, Would it be possible to have another gmail account (assuming you have some left)? If not, no problem. Appreciate the one I have! Thanks!
Cheers, Pat
Teaching: http://www.ualberta.ca/~pletendr/
TraQ: http://www.traqprogram.ca/
TraQ blog: http://traq.blogspot.com/
Consulting: http://www.patletendre.com/
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Hi, Cliff,
Gotta have gmail. Please send me one too! Thanks!
Cheers. Pat
TraQ: http://www.traqprogram.ca/
Teaching: http://www.ualberta.ca/~pletendr/
Consulting: http://www.patletendre.com/
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This also depends on whether a computer crossmatch is to be done and whether there is a previous record:
If a computer crossmatch is performed, the recipient’s ABO group must be
determined twice an ABO determination on the current specimen plus one of the following:
- second independent testing of the same specimen
- testing of a second correctly identified and labelled specimen. The
specimen may have been collected, identified, and labelled
concurrently with the current specimen.
- verification with results of previous ABO testing that are on file
Also, check out this AABB workshop textbook- it's old now but still makes interesting reading:
Maffei LM. Current state of the art. The survey:pretransfusion testing. In:Johnson ST, Maffei LM, Steiner EA. Pretransfusion testing:routine to complex. Bethesda, MD: AABB, 1996
Cheers, Pat
Teaching: http://www.ualberta.ca/~pletendr/
TraQ: http://www.traqprogram.ca/
TSO: http://www.transfusionsafety.ca/
CSTM: http://www.transfusion.ca/new/
Consulting: http://www.patletendre.com/
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Hi, all,
Maybe I've misunderstood what others have written, but anti-A1 (the type made by A2 patients) is usually (but not always) a cold-reactive clinically insignificant antibody. If anti-A1 in an A2 or A2B patient does not react at 37C, crossmatch compatible blood can be issued. There is no need to give group O or A2 RBC in these cases. Anti-A1 is the same as most examples of anti-N, -P1, -Lea, etc. If non-reactive at 37C, crossmatch-compatible RBC can be issued and antigen-negative units are not required.
Cases of hemolysis caused by anti-A1 produced by A2/A2B patients exist but are rare. Anti-A made by Group O and group B people (has a part that reacts with both A1 and A2 rbc) is another matter.
Cheers, Pat
Enzymes in UK antibody screening
in Quality
Posted
Thanks David & Pluto for replying.
Still would like to learn how many gel users in the UK use enzymes routinely...