Confirming D on Rh positive units using Echo

[heathervaught]

According to AABB Standard 5.12: "...The ABO group of each Whole Blood and Red Blood Cell component and the Rh type of such units labeled as Rh negative shall be confirmed..."

For those of you who use the Echo in your facility, do you also confirm the D status of Rh positive units, or only Rh negative as required?

[Malcolm Needs ☆]

According to AABB Standard 5.12: "...The ABO group of each Whole Blood and Red Blood Cell component and the Rh type of such units labeled as Rh negative shall be confirmed..."

For those of you who use the Echo in your facility, do you also confirm the D status of Rh positive units, or only Rh negative as required?

Would there be any need? You can't make anti-d!

(but then, I'm not covered by US regulations).

:confused::confused:

[heathervaught]

I am strictly talking about units of blood intended for transfusion - the ABO and Rh typings are performed by the collection center. The ABO must be confirmed by the transfusing hospital for all units, and the absence of the D antigen needs to be confirmed only on those units labeled as Rh negative. There is no requirement to confirm that the D antigen is present on units labeled Rh positive. I am told that there is no way to modify the testing performed by the Echo device to not require D testing when confirming types on blood units that are received.

[adiescast]

We have a Galileo and we did have to allow it to perform D typing on all units (not just Rh negative units). It was something to do with the programming. I don't know if the Echo is the same...

[galvania]

I have never really understood why the hospital that receives the blood from an accredited donor centre needs to re-check the ABD group of the blood bag. I would like to believe thst these donor centres have sufficient controls in place that if the label on the blood bag says A Pos, then the blood inside the bag really is A Pos....Am I being naive?

[Malcolm Needs ☆]

I have never really understood why the hospital that receives the blood from an accredited donor centre needs to re-check the ABD group of the blood bag. I would like to believe thst these donor centres have sufficient controls in place that if the label on the blood bag says A Pos, then the blood inside the bag really is A Pos....Am I being naive?

No!!!!!!!

:D:D:D:D

[heathervaught]

Well, I can tell you how this happens...and it's not usually that the test is performed incorrectly...

A unit of whole blood is collected. It is centrifuged and the plasma is removed from the RBCs. A filter is attached to the unit of RBCs for leukocyte reduction. The unit numbers on two units get switched and they are labeled with the wrong blood type.

Think of all of your WBIT situations in the hospital -- the same possibilities exist during the phlebotomy process. Bags or tubes are pre-numbered, someone removes the test tubes from the bag and sets them on a table, and so does the person next to them. They grab the wrong tubes and fill them up with the wrong blood. At least hospital phlebotomies are either performed in a designated phlebotomy area or in a patient's room! We collect blood in cramped, hot/cold, dark offices, warehouses, conference rooms...and even on busses!

Since the advent of electronic crossmatching, I think it is exceedingly important that the types are confirmed by the hospital.

-Heather (SBB!)

[Malcolm Needs ☆]

In the UK, however, all the side bags are sterily (if that is the spelling - not my best point) and labelled with the unit number prior to the blood being taken, so this problem does not arise.

:)

[adiescast]

I think Heather was referring to the testing tubes getting separated and mixed up, not the attached satellite bags.

We have seen this happen (very occasionally). We have also detected weak A subgroups that the blood center labelled as O. It does not happen often, but if it happens at all it is worth the time and expense. If I am not mistaken, even donor centers that also perform transfusion services are required to retype the units before use.

[adiescast]

Another thought: maybe there is a difference in how the testing samples are obtained in Europe? How do the donor centers there get their samples for testing?

[L106]

Back to the original question.......The Echo is like the Galileo in that there is no option to order and perform only the ABO Forward Grouping on the instrument. So, yes, if you use the Echo to do the confirmation recheck on donor units, it does the Rh Typing on all the donor units (not just on the Rh Neg donor units.)

This is a waste of reagents and test strips. Maybe if enough of us complain to Immucor they will invent a test for only the ABO Forward Grouping. (Although you would then have to pay attention and separate the Rh Neg donor samples and make sure that both the ABO and Rh testing is performed on those donor units.)

[Malcolm Needs ☆]

Another thought: maybe there is a difference in how the testing samples are obtained in Europe? How do the donor centers there get their samples for testing?

I don't know about the rest of Europe, but, certainly in the UK, the testing samples are taken from the line at the end of the donation, whilst the canula is still in the donor's arm, and are labelled with the same bar-code label as the unit itself at the same time.

I would imagine it is the same for the rest of Europe (or, at least those countries that are in the European Union [or whatever it happens to be called this week]) as they are all governed by the same laws concerning Good Manufacturing Practice; doesn't mean that they adhere to these laws though!

:rolleyes::rolleyes:

[carolyn swickard]

We have chosen not to do our unit retyping checks on the ECHO, partly for this reason (our retesting is the bare minimum), partly because we would have to reprogram the computer to accept the new patterns (not impossible, but time consuming considering the revalidation and such) and mostly because unit retyping is much (!!!) faster on the bench than on the ECHO for us. Now, we only bring in 15-20 units a day, I can imagine at bigger centers, with an interfaced computer (our's is not), that it would be well worth the time to just change the patterns and live with the preprogrammed testing patterns (it is a big waste of D reagent though). An earlier post had a good idea - we should all ask Immucor for an update for Rh pos unit retesting vs. Rh neg unit retesting - it's just programing after all - but you would have to keep those units straight!

On the other subject raised in this post - you used to find an occasional mislabelled unit (1 every 2-3 years) but I haven't seen one in years since the distribution centers went to computerized checks on the labeling. However, just when you think it is a waste of time to recheck and we should be able to drop the retesting, many more hospitals are going to computer crossmatching. In that case, if the transfusing hospital doesn't recheck the unit, there is no other check going on at all that proves that unit is what it says it is. So, my guess is - we will be retesting forever.

Edited June 3, 2010 by carolyn swickard

[adiescast]

I don't know about the rest of Europe, but, certainly in the UK, the testing samples are taken from the line at the end of the donation, whilst the canula is still in the donor's arm, and are labelled with the same bar-code label as the unit itself at the same time.

I would imagine it is the same for the rest of Europe (or, at least those countries that are in the European Union [or whatever it happens to be called this week]) as they are all governed by the same laws concerning Good Manufacturing Practice; doesn't mean that they adhere to these laws though!

:rolleyes::rolleyes:

So what process do you use to ensure that the pre-labelled tubes are not separated from the prelabelled bags before they are filled? I think that is where Heather was identifying the potential for errors.

[Malcolm Needs ☆]

So what process do you use to ensure that the pre-labelled tubes are not separated from the prelabelled bags before they are filled? I think that is where Heather was identifying the potential for errors.

I'm not sure, as I am "patient-facing", rather than "donor-facing", but I will make it my business to find out on Monday and get back to you.

[heathervaught]

Thanks for investigating, Malcom. In my institution (and in many others, I am sure), the primary collection bag, the attached bags for component processing, and the test tubes are all labeled by an individual before the phlebotomy is performed. Someone tapes the labeled tubes to the back of the container for temporary storage. Once the donor is seated in the chair, the donor's paperwork (demographic information, physical, consent, and health history) is labelled with the same number. The tubes must then be removed from the bag because the bag is placed on a scale. The phlebotomy is performed, and the first 40 mL or so is sent into a "diversion pouch", which hopefully reduces the risk of bacterial contamination by catching any skin plug and/or skin flora. The pouch is sealed and the tubes are filled. The phlebotomist is supposed to verify that the numbers match before filling the tubes, but there is a possibility that the set down tubes labeled 6234121 and accidentlly picked up 6324121 without realizing it. I do think that the use of the check character with ISBT has minimized the risk of this happening, since those letters or numbers in the little box are very useful when performing the verification.

Edited June 6, 2010 by heathervaught
poor grammar

[tricore]

I have never really understood why the hospital that receives the blood from an accredited donor centre needs to re-check the ABD group of the blood bag. I would like to believe thst these donor centres have sufficient controls in place that if the label on the blood bag says A Pos, then the blood inside the bag really is A Pos....Am I being naive?

The orign of typing units received from the supplier - the old verbage was "is the ABO/RH (neg) checked after the product is labeled". I have never had a supplier that checked (serologically typed) the unit after the label is applied. If the suppliers computer system has a label check program that they use after applying the label then maybe we don't need to do this anymore. However, I don't want to be the tech who performs an electronic compatibility and gives a mislabeled A to an O.

[Malcolm Needs ☆]

I'm not sure, as I am "patient-facing", rather than "donor-facing", but I will make it my business to find out on Monday and get back to you.

Well, Tuesday, but not bad for me as far as time-keeping is concerned!

Apparently, what happens is that a set of 13 bar code labels with identical numbers are torn from a roll, and attached to the Donor Health Check (DHC) paperwork, after the health check questions have been answered and this is put in a tray, together with the unlablled side tubes and the empty blood bag.

These are taken to the donor's bed side, and the first thing that happens is that one of these labels is put on the DHC. The next thing is that the tubes are labelled and filled with the donor blood (at the bedside, prior to the actual unit being drawn, through a sort of branch line from the main bag line). The bag itself is then labelled, and the unit taken.

All labels have to have an audit trail, and so any that are unused, or are damaged, are stuck to the DHC.

All are checked before the donor attentant can call another donor.

As far as I know, there has been one quality incident nationally involving a wrong label on a side tube in something like 10 years. It resulted in no clinically adverse sequalae.

:)

[donnalander]

The orign of typing units received from the supplier - the old verbage was "is the ABO/RH (neg) checked after the product is labeled". I have never had a supplier that checked (serologically typed) the unit after the label is applied.

When I worked at a blood collection center, we were required to retype the units and confirm the Rh neg units (through AHG) post labelling. We removed the retype labels before shipping; we did not use computer confirmation.

[tricore]

The orign of typing units received from the supplier - the old verbage was "is the ABO/RH (neg) checked after the product is labeled". I have never had a supplier that checked (serologically typed) the unit after the label is applied.

When I worked at a blood collection center, we were required to retype the units and confirm the Rh neg units (through AHG) post labelling. We removed the retype labels before shipping; we did not use computer confirmation.

Our supplier does not retype after labeling.

[adiescast]

Something else to consider - electronic crossmatching requires that both donor and patient have been typed at least twice. Since a transfusion service has no connection of a unit to the donor history, we would have to type the unit again. Fortunately, we are allowed to accept the label as evidence of the first type.