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DebbieL last won the day on June 22 2017

DebbieL had the most liked content!

About DebbieL

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  • Birthday 08/30/1955

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  1. Our QC was minimal several years ago based on the fact that the first ABO back type would confirm the antisera. The standard says the Anti-IgG reactivity is checked during crossmatching. I think our QC only had about 6 tubes and 1 gel card. Very minimal! But I started thinking that we didn't actually have proof the AHG worked on a particular day. (If it isn't documented you didn't do it) I thought proof needed to be added or some tech working that day would need to remember to mark the form hours later. I knew this would get missed multiple times in a year so I added these to the QC form. I even had them add the lot numbers of items that aren't QC'd like the saline cube or the AntiC3b,-C3b. If asked, I have a record of the lot numbers in use on that day if we should need cough up the lot number. Later I read that all reagents must have a check against known positives and negatives so I expanded the QC. It now has about 13 or 14 tubes and 2 gel cards. It is overkill but like I said they can't ding me for not doing enough. I would rather do too much than not enough.
  2. We have a dry erase board in an area that can be seen by all techs where we write general transient info such as 3 PLT ordered, # of available PLT, reserved PLT for heart surgery, etc. This info is erased as it is updated. Most of our issues seem to center around PLT. LOL I have a clipboard with basically a sheet with instructions on the top and basically lines and cues about date/time on the rest of the sheet. If we talk to a physician, nurse or blood center about an issue, we write the info on the clipboard. Some problems take up most of the page so they take as much of the sheet as they need to relate the issue. I'm sure some things are missed here and there but it seems to work for us. It is not perfect but nothing ever is. My techs are pretty good about writing on the clipboard.
  3. Our hospital only did the minimum for years and was never sited. However, a few years ago it seems like the CAP standard changed to read that all reagents must be tested with positives and negatives. Or maybe I REALLY read the wording closely. So I redesigned my QC with pos and neg for all reagents. And we do check the A2 cells everyday. I know if I left that off, my people would forget to do QC on the rare occasion they actually needed to use the cells. I try to stay ahead of the issue. I will say, I was inspecting a hospital about 2 years ago and I asked the person in charge of the BB about the negatives he wasn't doing. He pushed back really hard so I called CAP to get a ruling. CAP said doing only positives was OK and she sounded exasperated that I would ask such a question. I got the feeling she thought I was reading it too closely. I didn't change my QC after that call and I still feel better about proving over and above what is the minimum necessary to prove the reagents work. No one can ding me for not doing enough. The reagent use is minimal and I don't feel I am wasting reagents.
  4. I also called CAP in regarding this standard. It has been a while I was told we only had to compare kits such as the fetal screen kits. She said basically if there were positive and negative controls in a kit, we had to compare new with old. We did not have to compare elu-kits because there are no controls with the kit and all reagents used to test the eluate have been QC'd that day. I also heard this on a CAP webinar about the most common deficiencies a year or two ago. With regards to rare and not so rare antisera, we did not have to compare these at all because we do QC on day of use. I think she said something about FDA standards for potency. If they don't work, you don't use them. With regards to panels, we do not need to do QC on panels when they arrive or compare new to old. The new panels are made up of different donors from the old one, not a good comparison. Panels must be visually inspected for proper shipping conditions and documented this has been done. No other QC is required. She said if we use the panel cells as positive and negative controls when we perform antigen testing, you are actually performing pos and neg QC several times before the panel expires with no effort. A light bulb went off at this point. I have a new incoming reagent form we use and I added a column about the shipping conditions as acceptable or not acceptable with a legend below stating what is OK and what is to be rejected. We still use a paper form for rare antigen testing since it just works better for us. I added a column to insert the panel lot number used for controls and if the panel was visually acceptable when used. Bingo! I have documentation regarding visual inspections upon arrival and on day of use and can show panels used for antigen typing reacted as expected. It helps when you get to speak to a BB person at CAP.
  5. You do not need to register with the FDA if you are just pooling, thawing, changing FFP to Thawed Plasma or splitting units like for pediatric use. The end product is basically the same as the beginning product. However, if you take a product and make a new product then you would need to register with FDA. An example would be combining RBC with FFP to make whole blood for an exchange transfusion. The end product is different from the starting product. I found a good explanation for this on the AABB site. 2012 ASK THE FDA and CLIA Transcript question #29. You can access and print these transcripts even if you are not a member of AABB. Hard to find on the site but persist. A CAP inspector once told me I had to register with FDA because we used Thawed Plasma. He had a VERY superior attitude that he knew ALL things BB and his mission was to impart his wisdom to someone so inferior to him. I knew he was totally wrong but I wasn't going to call him out during an inspection. I'm dumb but not stupid. LOL
  6. We use the J series for antigen typing. The way I read it, the J series includes antigen typing and it is an CAP approved PT since they make it. They probably would like us to order the RCBCAT since all their PT are pricey but I think "J" meets the letter of the standard. We will be inspected in the sprig, I will see if I get called out on this.
  7. Remember, you have to follow it to a "T" if stringent rules are written in a policy. You can be dinged for not following your policy. I would be a bit vague when writing the policy with a lot of wiggle room: wash hands after removing gloves or when leaving area, no lab coats outside of lab area, no eating or drinking or applying makeup, etc. All of our area is considered dirty, including phones, community pens, benches, door knobs and refrigerator handles. We couldn't swing a clean area and a dirty area here since everything is in one room with phones and computers scattered around. All it takes is one person with gloves answering a "clean" phone on a busy day to mess up everything. I agree with Ensis01, if it is too hard, your techs won't adhere to the policy and an inspector would notice. PPE is available to protect the tech and is readily available for them. If someone wants to be absolutely safe they should wear gloves all day no matter what they are doing and consider everything dirty. (I never thought of putting tape on paper with blood spots- good idea)
  8. I am on the trauma committee where I brought up the idea of using A plasma instead of AB several years ago. The head Trauma physician was there and thought it was a great idea. He just wants plasma when he needs it. I approached our Medical Lab Director and had to provide him with documentation I found from Mayo so he felt better about it. Unfortunately, my pathologist limits us to only 2 until we have a confirmed blood type. I pushed for 4 but couldn't change his mind. I wrote up my policies and was done with it. I did not bring this up to nursing We keep 2 A thawed at all times. We rotate it by sending thawed plasma to surgery when they need it and thaw out more. We discard very little except around holidays when there is not much surgery. It works for us.
  9. I just answered this question. My Score PASS  
  10. We have a process to extend the crossmatch that has worked for several years. It is complicated and involves 3 departments. Everything has to be exactly right. The patient comes in to pre-test. We have a form that is put with the pretest packet. On the top part of the form is the patients info along with today's date and expected date of surgery. The nurse asks the patient two questions- have you been pregnant or transfused in the last 3 months? The nurse signs her credentials and sends the form to us along with the specimen. We perform a T/S and write our info into a section for the BB. There is a spot on the form that we put whether we need a second type on the morning of surgery. We put a sticker on top of the tube to signify the tube has to be saved when specimens are thrown away. Two days before surgery, the night shift faxes the form to surgery holding so they can put the forms in the charts. The morning of surgery, the nurse scans the form to see if they need to collect the second specimen and they ask the patient if they have been pregnant or transfused since pretest. Nurse signs form and faxes to us and sends the 2nd specimen if required. We get the form, do the second ABORH, find the original specimen, look at form for all signatures, etc. If all the stars are alligned, we order a specific test in the computer which extends the crossmatch for 3 days, answer the specific things in the computer and perform an electronic crossmatch if the physician wanted blood set up. If the patient had an antibody, we request a new specimen on the morning of surgery to do a new T/S and crossmatch the units we antigen typed before the patient arrived. Works great. Most are only T/S done 3-5 days before surgery with the occasional cancelled surgery that tries to get in at the end of the month. We tried to do 14 days but extended to a month (30/31 days hard stop) because the physicians kept pushing the envelope. We did 30/31 days because it is easy to see if the surgery was canceled for too long. If there is any question about ANYTHING, a new specimen is collected and we start over. It works well for us and we have had very few problems after the nurses realized it helped them
  11. We have one form- Emergency/Medical Release form. Top portion is Emergency release with one of 2 parts we check- Emergency O uncrossmatched or Emergency type specific uncrossmatched. An emergency situation exists and transfusion prior to completion of testing is necessary due to life threatening conditions. I have been informed and understand the risks blah, blah blah. The lower portion is the medical release with things we check, AB of undetermined, compatible units available, AB of undetermined- unable to find compatible, Rh positive product to Rh negative female of childbearing age, Blood Consent signature unattainable, Other. I am aware of problems encountered during compatibility testing. The medical status of this patient necessitates blah blah blah. I have been informed and understand the risks involved blah, blah, blah. Physician signs at the bottom. Our policy states that we do not have to have the signature prior to either of these conditions. If it is an emergency, we will get the signature when the crisis is over. If it is medical, we call the physician and tell them the issue and tell them they must sign the form. We will allow them to sign the next morning. If they don't sign I sic the HIM department after them when the patient is discharged. The physicians get in trouble here if they don't sign their orders. If it is something that is really out of the ordinary, I have my pathologist talk to the physician.
  12. Sorry for the delay in replying. I am not receiving this newsletter in my email anymore for some reason. Yes we use Cerner. I don't think the baby and mom are linked. If they are, the lab can't see it on our side. We used to put the cord blood workup under the mom's number. That changed when the EMR came along to foul things up. Now the baby is ordered under their own medical record number. We have L/D wrap a mom's chart label sideways on the top of the cord blood and the baby label is placed up and down in the normal way. That way we have the mom's name and number when we are putting in the baby results. We look up the mom to make sure we have a current blood type. If current, we type the mom's type into the results. If it is not current, we get a new specimen. Blood Bank history is not always reliable. Unfortunately, the computer doesn't compare the baby type to the mom type, we have to do that. Talking about the history is not always reliable..... a patient came in to have a baby. The blood type didn't match the history. Had her collected again. It still didn't match her history. Started digging in the computer. Turns out, she had a baby 3 months earlier. (???) Called L/D to see if this was some type of weird OB case. No, it turns out the one that gave birth 3 months earlier had a Medicaid card and it worked so well when she gave birth that she loaned it to her friend. Just a little bit of fraud. Go figure. Never rely on computer history
  13. Our previous computer system allowed us to put in the antigen typing QC when testing patients and donor units. It was horribly cumbersome. Our rule here is that we only do QC on antisera once in a 24 hour period, starting at midnight. We could never tell if QC had been done by an earlier shift on a particular antisera so we would do it again. My boss finally relented and went back to paper forms due to cost savings and we also saved tech time and frustration by using a paper form. Are you using a shared excel sheet that all techs use to enter QC? If I was inspecting, I would want to know how you could protect the info already entered, e.g. could someone change the entered information whether intentionally or by accident. In order for things to be added daily, you would need to prove that previously entered info is secure. If it is not secure, how would you know if something was changed on a excel sheet? Could you see a print out of the changes and who made them? I have had files disappear. Yes, our stuff is backed up but you have to tell the IT people when you thought it was deleted so they can look thru the dumped files of the whole system. I have lost files myself by moving them accidently to another file. I freaked out for a period of time. How would you document review within 30 days? You would need to add your electronic signature and date and it couldn't be changed or altered. If there is something wonderful out there, I am interested. Otherwise I will stick with the old fashioned paper forms. They don't take up much room in a file and I don't have to worry about them disappearing into nothing. I think I'll let the next supervisor do something wonderful when I'm gone. There are just too many questions surrounding electronic QC. (I sound like an old fuddy duddy. LOL)
  14. We just use regular clear tape like you would use to seal a box. About 3 inches wide. I do admit the tape starts peeling up after a year or two, so she could have a valid point. I have typed up instructions for the outside and "laminated" with the tape. A lot of good it does since they don't seem to read what is in front of them. A different lady in Quality suggested we use the sticky pouches so we could put the patient name on the outside. I don't see the difference between a sticky pouch and sticky tape but whatever. I think I will redo all the coolers with new tape and see if I can get it past the next infection control person. We have had several in the last few years. One concentrated on corrugated boxes and upended the entire hospital.
  15. We use 55. My CMO and pathologist declared that was the outer possible limits. I wanted 50 but was overruled.
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