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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

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 sho

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 prewar

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 acqui

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. Fortun

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

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 sam

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 invo

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

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 th

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 serie

Couldn't agree more Mr. Staley. Humans are what would keep me up at night. I was just suggesting that pneumatic tube systems have advantages but also new opportunities for errors, mechanical or software related and may introduce new types of machine/human interactions that may lead to a new set of human errors. This was a new realization for us and required more awareness training to hospital staff involved with the pneumatic tube system. I just would like to encourage TS supervisors to think outside the box as this type of machine/human interaction is likely to increase and may introduce

Just a note of caution. The only issue that was observed with pneumatic blood transport was the following; A tech sent a crossmatched, tagged unit of red cells to the 5th floor nurses station for patient A. Twenty minutes later a tech sent a crossmatched, tagged unit of red cells to the 2nd floor nursing station for patient B. A few minutes later the 2nd floor nurse called the TS lab and indicated they had already received the red cell unit for their patient B and did not need the 2nd one. ?? That's right, the first unit that was to go to the 5th floor was misdirected by the tube system and

I apologize for such a late comment for this topic and possibly bringing up minor point regarding this typing. I'm sure that the probability that the reactivity with the A1 red cells was confirmed by testing other sources of A1 red cells to rule out the possibility of a antigen of low frequency on the initial A1 red cells tested. I just did not see this mentioned in the comments. The blood center where I had worked took deferring donors very seriously as it affects the blood supply and the donor's altruism. Mr. Needs response and explanation of A subgroups is excellent and I always appre