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Christy Spence

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About Christy Spence

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    Junior Member
  • Birthday 05/29/1982

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  1. Our blood bank policy states to use 2 patient identifiers on our blood bank samples; med rec number and full name. We use the Typenex system with pre-printed labels (chart labels that match our hospital bracelet stickers) that adhere to the patient's blood bank bracelet. Policy requires the person drawing the patient to verify name and DOB in addition to the med rec number prior to draw. The label on the actual tube is generated from our computer system- Cerner. It does not include the DOB but it does include full name, MRN, and accession number. Our interim director is extremely concerned that we do not have DOB on the actual sample. It's my understanding that full name and 2 unique identifiers, MRN and Typenex number, meets accrediting requirements. Does anybody else require more than the standard 2 patient identifiers on their samples? Am I missing a significant CAP/TJC/AABB requirement for DOB?
  2. Christy Spence

    TRM.42750 Storage Unit Alarms

    TRM.42750 Storage Unit Alarms for the transfusion medicine checklist dated 8/22/18 was revised to state that, "The Laboratory must demonstrate that all components of the alarm system (including manual chart recordings) work as expected...." We have been doing the electronic checks at least quarterly but these do not show up on the graphs. Just curious what others think of this! I'm assuming we will need to go back to doing manual alarm checks with the ice water
  3. Christy Spence

    Antigen Tested Units

    This is our policy as well.
  4. Christy Spence

    A1 Lectin Proficiency Testing

    Proficiency Testing
  5. Christy Spence

    A1 Lectin Proficiency Testing

    During my CAP inspection I was cited for not having PT for A1 lectin and weak D. We rarely if ever use A1 lectin as we send out our ABO discrepancies to the reference lab. I will remove that from our ABO Discrepancy policy. However, we do perform weak D testing on cord bloods and prenatals. The person inspecting me said he was cited, hence why I was being cited. How do other facilities handle PT for weak D? I don't think CAP offers weak D PT... I had no idea either of those required PT, but I guess it does make sense.
  6. Christy Spence

    Misidentification risk mitigation alternatives

    I'm interested in knowing this as well... We are not a level 1 trauma center so this isn't a huge issue for us but it isn't easy to obtain O units either.
  7. My facility currently uses the Typenex system. We've used it for years (at least 12+) and have had great success. Our CAP inspectors have been satisfied with our protocols so far. One of the main CAP Transfusion Med. individuals (not sure of the right title but I don't want to call them out by name...) stated very clearly during a recent webinar that typenex is not an acceptable method for misidentification risk mitigation (see TRM30375). Our inspection window starts in 2 months and I'm trying to gather as much info as I can on our options. I know I will get major pushback from our docs here if we try to push through a second sample verification system. Anybody else out there in the same boat? Please share your experiences and advice with transitioning to a different ID system! I'm wondering if getting a barcode scanner/printer for the bedside in addition to the typenex system would be the least impactful option at this point
  8. Christy Spence

    Ortho Panel Cells -Quality Assurance

    We use 1:9 dilution of QC antisera (anti-D & anti-c) upon arrival / prior to use. "Periodically" and "weak antibodies" are way too vague...
  9. Christy Spence

    testing for transfusion of platelets

    We require a current sample with Typenex band.
  10. Christy Spence

    Expired Panel Cells

    AABB and CAP didn't respond to the CLIA rep's comments. We use expired panel cells for rule outs only and run controls with each cell (anti-sera and diluent for gel). Since we are a smaller facility, we rely on this practice as we do not stock more than 1 in date panel. If they decide to go down this road, I'm afraid we will be sending workups to the reference lab more often. I have no interest in LDTs! And as far as I know, reference labs have been trying to get some sort of exception for their use of expired reagents.
  11. Christy Spence

    Expired Panel Cells

    I just finished listening to an ARC webinar that included accred reps from CAP, AABB, and CLIA. A question regarding use of expired panel cells was brought up and answered by the reps with, what sounded to me like, some hesitation. CLIA added that we are required to add a disclaimer with each test report in which expired panel cells was used. Something along the lines of it not being an FDA approved reagent, yada yada yada...AND that this will be considered an LDT. Yes, the dreaded laboratory developed test. Have any of you ditched the use of expired panel cells altogether? Are you currently validating as an LDT, including using the disclaimer on each test result? I guess this CLIA person threw me for a loop. Christy
  12. Christy Spence

    QC on Panels

    I use Ortho Panel A and Ortho Gel Screening cells. We run Ortho Confidence 1:9 daily on our screening cells. Thoughts on using the same dilution on the entire panel after receiving it to satisfy the product insert recommendation? "Periodically" to me is open to interpretation, just as the entire concept of running QC on panels is open to interpretation.... I figure if the control dilution is good enough for our screening cells used for detection, it is good enough for the identification.
  13. Christy Spence

    Customized Checklists for inspection

    How did you acquire a customized checklist from CAP? I didn't know this was an option!
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