Trm.40800

[LAS0039]

Is there a mechanism to ensure that Rh immune globulin is administered to all identified candidates within 72 hours of an alloimmunizing event, whenever possible?

How are you complying with this requirement?

[Lcsmrz]

We scan blood bank printouts looking for candidates and proper follow-up. We also have a hospital policy for those situations that never make it to the blood bank's attention.

[vilma_mt]

I don't think Lab has the ability to screen each and every patient. It is a hospital policy. I suggest find this policy and make a copy for Blood Bank for Blood Bankers to refer to during inspection.

[velliott]

Most of the policy for making sure RH IG is administered goes back to the OB floor. I've always worried about this standard and we currently do not have anything in place in the blood bank to make sure patients get their dose. I guess the LIS could write a crystal report that would include all RH negative patient's tested within the past 24 hours. Staff could then check the report and then see if the dose has been ordered.

[velliott]

Also another comment. We dispense RHIG out of the blood bank. Once it is ordered we can make sure it is given. I've had to fight for this also but my story is that there have been 3 instances in the past 6 months where it was obvious someone who knew what the reasons for administration needed to be in control, e.g. blood bank.....

1. wrong dose - ED wanted a mini-dose. We stopped stocking mini-doses because of patient safety....everyone gets a full dose. The ED physician insisted on the mini and had many conversations with the techs.....the patient was 16 weeks.

2. inappropriate dose - patient had been an anti D titer of 128, we had performed titers throughout her prenatal....the floor wanted it because she was RH negative...didn't have a clue she didn't need it.

3. missed dose.....patient was discharged and dayshift found the injection in the refrig from the day before...patient was called back in to get her dose.

[adiescast]

RhIg is ordered by the OB physician and dispensed by Pharmacy. Blood bank is not involved in the process at all. At this point, I refer the inspector to the hospital poilcy. Our last inspector wanted me to audit Pharmacy's process. I can see myself going to them with my hat in my hand (figuratively) and saying "I have to make sure you know how to do your job..." How would we feel if they did that to us?

We did have to go to the OB group several years ago after we were cited in an inspection for not being involved in the process. The doctors told us to stay out of their business. They wanted to be responsible for making sure the patients received their medication and I don't blame them. I'm not checking albumin or Factor injections, why should I check RhIg injections? At some point you have to accept that we are not in control of everything and other medical professionals can be responsible too.

OK, I'll get off my soapbox now....

Edited April 15, 2010 by adiescast
I got **** for a word that is a generally acceptable reference? I replaced the word with "stay."

[L106]

About 20 years ago, our Pathologist decided that Rh-Immune Globulin was a drug, and, as such, belonged in the Pharmacy Dept. I kicked and screamed (well, I wasn't quite that volatile), swearing that "No one could do as good of a job as the Blood Bank Dept." Well, that may or may not be true, but (to my knowledge) no one has died because of the change in policy. So now I pretty much follow adiescast's view on the topic.

However, I still do get upset when a situation arises that reveals that many OB nurses are pretty much "clueless" about the product they are administering (as in velliot's example #2 in her earlier post.)

[BBK710]

Our maternity unit has a standard order set that requires an order for a blood type on each patient admitted in labor. We document all Rh negative patients on a paper log. We then check for the receipt of a cord blood and an order for Rh Immune globulin. If we don't receive either we call the floor and ask for orders. Is this perfect? Of course not, it assumes that we receive an order for a blood type for all patients admitted. We know that we don't because occassionally we receive a cord blood and when we check the mom's blood type we find that we never got an order for one. However, it's better than nothing and we have had no problem with CAP inspectors.

Edited April 16, 2010 by BBK710
spelling

[roberman]

The OB dept sends cord bloods from all babies of Rh neg moms. If the cord blood is Rh positive, the lab orders a fetal screen and RHIG. If the RHIG is still sitting on the shelf at 48 hours, we call the OB dept.

[Eagle Eye]

same here. Blood bank is reponsible to make sure patient gets RHIG within 72 hrs from delivery. We have several checks in place so we do not miss this. we had few cases were patient went home AMA and we (notified clinician&)documented information to fulfill the requirement.