mrmic

As for why they might be ordering??? Just fyi..... I had only one interesting time which we followed these titers closely. There were transplant physians studying the possibility of neutralizing the A and B antibodies that were incompatible with the transplanted heart with infusion of high doses of the corresponding sugar that represented the A or B antigen. Later they also attempted to do the same with anti-species antibodies. If memory serves me, these were conducted in the 1990s. I believe the lead was Dr. D.K. Cooper. If anyone would like the references, I believe I still have some of the papers in a file cabinet.

I agree with everyone! However, the specific antibody ID methods and/or the titration methods alone do not affect the decision process for the pregnancy. A significant antibody identified or a significant change in the titration result does. But, only does if there have been reported cases of harm to the mother and/or infant based on the specific antibody identification and using the specific method of titration. A lot of the literature in the (ancient?) past showing correlation with potential harm to the infant were done with saline and/or dilutions of percentages of bovine albumin. Some of us "old farts" still remember those old reports. With all the new reagents or methods that are available now, it requires BB technologists to help initiate the investigation and follow up with the physians to report cases of a positive or negative outcomes of pregnancies with the different laboratory methods. Based on that knowledge, the technologist can select the best antibody identification and titration methods for following pregnancies and the physician can make the best medical plan of action for the pregnancy. So the best place to start; researching literature then working with obgyn physicians in your area to correlate the best laboratory methods with the best patients' outcomes.

Interesting issue. I agree with what you have presented. Trying to create communication with the transplant team is the best direction to go. In my past experiences with transplant/BB issues we found it better for the BB Supervisor and the BB medical director to meet with the Chief of the transplant service. Inquire why these tests are being ordered and why we are concerned about the tests being ordered. If there was a reason the transplant physians were ordering these tests, maybe we could help them by suggesting the best laboratory tests to help achieve their goal. (Research or treatment monitoring, etc.) If the Chief of service agrees with your concerns regarding the testing, he/she will discuss with his transplant team. Orders from the top - down within the service works best for getting the team to change their ordering practice. In addition, by offering the willingness of the laboratory to help the the transplant team accomplish their goal, if approved by the Chief of the service, we (the laboratory) comes across as not to be telling what they are doing wrong but to offer our help to order the necessary, correct tests that would help their goal. Good Luck

I have worked in both departments. Technically there is no problem as safeguards are in place as stated earlier. However, I do see an issue that, as a previous Transfusion Service (TS) supervisor, I would insist a new dedicated BB centrifuge be obtained. There are more times in TS when critical patients, especially neonatal, that require emergent blood products. For the survival of the patient and transfusion safety of the blood products, the appropriate products and aliquots have to be prepared in the Transfusion Service as quickly as possible. The centrifuge and required material and products must be in the Transfusion Service laboratory and available for use 100% of the time. There is no calculation or predictability of which neonate being at risk or when the need will arise. But it does happen. The cost of a centrifuge is not even close to even one neonate life or how it affects the family. Whether it is 1 a year or 1 in a hundred years. There is no regulation to state this. Do we really need one, I'm not even going to ask! Be on record that you requested a new centrifuge ASAP!

Although the question and answer are troublesome the following statement in the "question" cannot be ignored. (Investigation of the label issued at the blood bank verified the unit's correct labeling.) Since the blood center typing was investigated and verified the label was correct, then, the typing at the transfusion service should be suspected. The information put forth by Malcolm and Johnv seem likely if one investigated the transfusion service typing. Donor centers are quite aware of regulations regarding donor testing and labeling. So not all suspected "mislabeled" units should not be automatically the donor center's error. They employ SBB technologists too. Their investigation should be discounted. Based on what the author was expecting to be the "only" correct answer, certainly reflects the problem of the way the question was written. It's not always easy writing "critical thinking" Immunohematology questions. So it might be an exception for the author of the question and not the norm. However, it did succeed at providing some stimulated conversation and valuable references for all!

I would get more history first. Transfused when? How much and/or how often? With what, rbcs, plasma, platelets, Immunoglobulin? Why? Diagnosis? Meds? Age of patient? Pregnancies if female? Previous antibody test results and methods utilized? Any results of extended rbc testing previously done available? Any other lab results suggesting rbc destruction or decreased rbc survival of transfused red cells? DAT negative but autocontrol positive? Could transfused red cells be present? Early production of cold reactive auto or allo antibodies showing up? As previously suggested try prewarming saline technique with no enhancement media, 45-60 min incubation with IgG reading only. Could be cold and warm reactive auto or allo antibodies present. Based on patient and testing histories should help with making a decision on what to do serologically. It's a little troublesome if this type of reactivity is seen often in BB? Unless there is some common issue with these patients, it may be something with regards to the actual methods or techniques used in the lab and not really a patient issue at all.

Definitely enough story lines for a mini-series! These are all possible stories that could happen to any of us. Being in direct contact with physicians (who know everything) and nurses (who believe policy is not practice) and providing products that could be life saving or harmful to patients and parts of the process is out of BBs control can be very stressful for technologists. And sometimes is hard to get new technologists to work in our field. With providing administration with some of these "real" scenarios and the possible medical-legal-pr implications I was able to acquire an additional salary % for techs working full time in the transfusion service. When other department techs thought it was unfair, I asked them to apply for a BB position (no takers). Might be worth a try if you need techs. Thanks to all who are sharing your experiences.

During the time at the Immunohematology Reference Lab I was at in the 80s-90s era we had to use microscopes to confirm negative reactivity. What!!? Why?? Specimens sent to us with multiple 2+ and 4+ reactions to panel cells were sent to us for investigation. We observed 0 reactivity! The hospital techs would get very upset with us because they were absolutely sure of what they observed and we found nothing! As it turned out, some hospitals, using microscopes, were grading their microscopic reactivities on a 1+ to 4+ scale but just not informing us it was microscopic reactivity. Fortunately we were able reduce these practices by providing CE during our quarterly member hospital meetings we conducted throughout the state. We still got them occasionally but when we see the possibility of this scenerio we look for reactivity microscopically. When we call the technologist we can then "confirm" what they are seeing but then use the time to educate and give them some assurance that the transfusion should be uneventful.

I had a BB technologist hand me the phone with a surgeon in the OR requesting two units of blood be brought to surgery, refusing to do any paperwork or provide a blood sample and a verbal order was all he would provide. According to the physician, as the physician in charge in the OR that was all the justification needed we must do as requested. That was the according to state law. We did not have a BB certified pathologist at the time, the general pathologist indicated to comply with the physician's request, and had a Resident physician in the lab come get the units (O RH Negative) to take to the OR. We had similar "to comply" situations with this "pathologist group" hired by the hospital corporate office. The rumor was, if the "group" received poor ratings or complaints from the hospital physicians their contract would not be renewed. When I began my laboratory career the pathologists were actually hospital employees and could tell physicians what they needed to do, the right thing to do, without fear of a contract renewal. The newer "corporate" model of hospital administration is scary to me.

Thank you Malcolm, but no worries. Certainly nothing to disturb a fellow retired BB. I only threw the topic out there to see if any previous members of SCARF were out there to share some stories with this group. I wish I would have kept my SCARF membership list when I retired. I recall several of the stateside British Mafia BBs being on the list. Plus I think there were a few other countries represented. Maybe Wolfgang Dahr in Germany, but that may have been a separate request for something more specific. It may be that more regulations and costs came around to interfere with sharing samples per professional courtesy. Not only was it great for obtaining rare examples but was also educational for staff and students. For some peaked their interest in the field of Immunohematology, which was rewarding to see. And with that I must say I have been very impressed with how you have responded, shared your knowledge and patiently helped those throughout the various topics on this web site. Thank You!

I see there has been quite a few views but no comments. Sooooo.... the S.C.A.R.F. group (Serum, Cells, And, Rare, Fluids) would share samples of interesting cases they had investigated. Each person would send out one sample to each of the other members in the group once a year. Everyone benefited by having a rare samples from which they could freeze aliquots. These would be available for aiding in future investigations of challenging patient specimens sent to their Immunohematology Reference Lab. At the time I was a member, I believe John Moulds was whom monitored the group I was involved with sharing samples. I'm not sure if there were multiple groups and who may have also involved with the members in the groups. Neither am I aware who took over the group I was participating with when John left the group. I posted this topic for out of curiosity to see if there was still a SCARF group or similar still active. It is possible that there are no longer groups like SCARF out there or no past members on this site.

Sometimes I forget what I forgot? What happened to the S.C.A.R.F. group? I don't see anything on this site mentioned about it and it was a great exchange program for Immunohematology Reference labs. It was going through some changes when I changed jobs and left the membership.

Ok, I'll start. The story of "Who turned off the Light". The year was 1999. Hospital "Notme Medical Center" supported an outpatient clinic for patients requiring transfusion, some due to sickle cell anemia. Often these were young adults that came into the clinic very early in the morning. After their blood was collected and they were waiting for the crossmatched packed red cell units to arrive, the patients preferred to sleep (pre i-phone years). Normally at least one light was left on, usually the bathroom light, while they were waiting. At 0530 the first of two tagged crossmatched compatible group O RH Positive red cell units was verbally crosschecked with the nurse Jane at the transfusion service door to be taken directly to patient Smith's room for transfusion. At 0625 the first of two tagged crossmatched compatible group B RH Positive red cell units was verbally crosschecked with nurse Kathy at the transfusion service door to be taken directly to patient Brown's room for transfusion. At 0633 nurse Kathy called the transfusion service to see if she could return the blood for patient Brown since someone had already started the first one. What! Said the BB technologist, the one I just checked out with you was the first unit for patient Brown. Follow-up: Nurse Jane had crossed checked the tagged red cell unit for patient Smith with another nurse at the nurses station and it was for a sickle cell patient in room 123 bed A. She went to the room she normally has gone to in the past, and when she looked into the room, although the lighting was low it was enough to see it was a young adult black patient in the room in bed A. Although a little groggy, the patient confirmed she was expecting the transfusion. After starting the unit, the patient appeared to tolerate the transfusion well and the nurse left the room. After speaking with the BB tech about returning the unit for patient Brown nurse Kathy went back to the room and discovered patient Brown was in bed A and had a red cell unit almost completely transfused but was unit was tagged for patient Smith. Patient Smith was in bed B. Both patients were young black adults but had switched beds because patient Smith did not want to be in the bed close to the door. Luckily the group O unit was compatible with patient Brown and was tolerated well by the patient. Needless to say, we required Nursing Education Services to review policies regarding the importance of patient identification and cross checking the tagged unit with another nurse at the bedside NOT at the nurses station. A poor practice that seemed to pop up once in awhile.

SHOT report sounds a little "official". Although I'm not suggesting that serious hazards of transfusions not be reported as required, there are some events that sometimes remain "in-house". Having been in BB 40 years and worked for various transfusion services and few Immunohematology Reference labs for other hospitals there are some interesting stories to tell. Some may be helpful to facilities with newer TS or QA management. Some may be a little comical, some scary and some shedding some positive light on the lab saving the day. Just thought it would be an interesting topic to read through and I'm sure everyone could share something. Except for CSI, most series are nurses or doctors saving the day or coming to the lab and doing the testing (haha).

Would there be any interest having a topic area to share transfusion error stories? I thought it might be useful for Supervisors, QA and other transfusion services staff to hear accounts of problems that have occurred in other hospitals. It could help with training laboratory, nursing and medical staff. It could be lab error, patient ID error, transfusion error, donor center error, etc... No specific person, hospital, blood center identification, state or country ID. Or is there some taboo about putting this info out there? If there is, we could say it is research for a new TV series....... If there is no interest that's fine too, no worries.