Issue of Rh pos RBCs to Rh neg patient

[bmarotto]

When you are in a situation where you must issue Rh Pos blood to an Rh neg recipient, do you have to provide documentation to nursing that this has been approved? We have no problem with the ED and OR when we switch a patient but the post-op nurses in the SICU, CTPACU say they won't take the "word" of the blood bank staff that we went through our standard approval process to make the switch.

[Mary]

Have your pathologist call them.

[bmarotto]

So, Mary, I take it you do not give them anything in writing that the switch has been approved? The nurses want us to get the responsible PA or resident to write an OK order in the chart. My response to that is inclined to be:

1. Add at least 5 minutes to the time for getting blood to your bleeding patient while my tech tracks down a PA or resident.

2. My techs may not want to take your nurse's "word" that the approval order has been written so fax it to us before we will release blood. Add a few more minutes there.

3. Considering most of these patients have already received Rh positive blood in the ED/OR...how is this is improving patient care?

Sorry, I am being a cranky old Blood Banker today.

[jhaig]

We use a standardized form for all emergency transfusions that is used for either emergency transfusions or life-threatening situations in which an Rh-negative patient may need a transfusion of Rh-positive blood. It requires a physician signature before any release of blood is allowed. We also require that the pathologist make the final decision on whether or not to give an Rh-neg patient Rh-pos blood.

[rcurrie]

Education, education, education. I have no trouble at all with any nursing unit when we make the switch from D neg to D pos blood. It's not that they just take whatever we give them. It's because they know in advance what our policy is. I am a regular contributor to the nursing newsletter. I am such a regular contributor that many nurses are surprised to find out that I am not an RN.

BC

[bmarotto]

Bob, this all started because on our old large unit tags we would electronically add a comment that said issue of Rh positive blood had been approved by a BB physician. The institution approved switching to smaller crossmatch labels that are affixed to a transfusion mount sheet (six labels fit on a mount sheet). The request for the smaller labels came from the OR and acute care nurses. I have tried explaining that the SOPs have been revised and await Medical Practice & Utilization Committees' approval. There will be no reference to an approval comment on the unit tag/label. There is also a statement that it is the responsibility of the BB tech to follow policy regarding obtaining approval from the BB physician for making the Rh switch.

Nursing insists it is their responsibility to ensure a "fatal transfuaion" error does not occur. I wish they were so diligent about this when they draw and label specimens. We are dealing with a completely different issue here. I am keeping my fingers crossed that our medical director will go the education route with me instead of placating nursing.

[rcurrie]

Good luck, Bev! Our SOP allows us to make the switch without any MD approval based on strict guidelines (inventory levels, age and sex of the recipient). You might want to ask anyone who gives you the "fatal transfusion error" argument to show one single case where a D neg recipient died from a D pos transfusion.

BC

[bmarotto]

We just got on the Med Pratice & Utilization committee agenda for Monday! Essentially, we are prosposing rewording our SOP to reflect the standard of care: Switching to Rh positive blood is a decision made by the Transfusion Service. No additional physician order is needed.

[rcurrie]

Good luck! A couple of months ago our O neg supply became "dangerously low" (by our standards, anyway- it dropped below 50 units). In order to protect the O neg supply, we issued O pos emergency release uncrossmatched blood for all male traumas and for all female traumas over the age of 50 (hey- we were right 85% of the time!). Right now we have almost 100 O neg in the shelves, so we are issuing O neg for unknowns again.

BC

[Lcsmrz]

I worked at one wonderful place that had a sticker that said "Blood types do not match. This is intentional."

[bmarotto]

Love the sticker!

[Karen Olsen]

We have set criteria that needs to be met prior to switching to positive blood. We also have to have Pathology approval and inform the attending physician. Beyond that we have stickers that go on the units stating that "due to inventory limitations, a medically appropriate blood group substitution has been made". Normally these stickers are used when we switch blood groups due to patient special needs - like antigen negative blood. But we could also use them for the Rh substitution to allow the RN to feel more comfortable about the transfusion.

[rcurrie]

I worked at one wonderful place that had a sticker that said "Blood types do not match. This is intentional."

A lawyer's dream, Larry!

MURDER: The intentional unlawful killing of another human being.

BATTERY: A voluntary and intentional act resulting in the infliction of a harmful or offensive touching of the plaintiff's person.

BC

[irshadaad]

we consult our consultant and inform the incharge doctor of the pt if the doctor incharge is willing to shift we make them to sighn the emergency release form.....no head ach with the nurses