Eoin

Hi umeshkumar, Liz succinctly listed the answers above and I concur entirely. You should definitely not ask anyone delivering the specimen to the lab to change anything, and they would be stupid to do so. They are opening themselves up to any subsequent litigation should there be any adverse outcome. Rejection of specimens should improve practice, but you need to keep the metrics on this (using Incident Forms or Specimen/ Forms Issues Register as described). If it is currently at an unacceptable level, you need re-education of staff taking the samples now. I know it is tempting for expediency sake to ignore minor errors, but then the line cannot be drawn. It has to be a zero tolerance policy to errors in any phase (pre-analytical as here).This issue is irrespective of manual system or HIS/LIS issues. Good Luck with it. Cheers Eoin

Thanks for post Mabel. I knew Joint Commission was going to get us to measure this as a KPI, so can start now. We have a very well used pre-op clinic and we keep plasma for 30 days (with the usual provisos - no pregnancy, Tx in last three months or between pre-op draw and surgery). Despite this we get elective patients turning up late & need Group, Screen & Hold or X-match. As soon as we see this, we send a letter (copy kept) to the anaesthetist in theatre warning that there may be no blood ready, especially if we encounter an antibody - etc, etc and the responsibility to proceed lies with them. We ask for a signed reply (but rarely get it mind you), but we feel that is the best we can manage. Cheers Eoin

My most exciting antibody was years ago in Oz - an anti-Gerbich in a New Guinea native woman. VERY exciting - OMG - don't tell me I'm like all you other nerds!!!!!!! Cheers Eoin

Any post workup would be directed by patient's condition. If there was no improvement in S&S we would suggest a full workup. Like others, we perform platelet count post infusion of plt packs - again to check to make sure patient is not refractory. No good pouring more good platelets in if they are being wiped out. Consultant Haematologist would then suggest IVIg in that case. Cheers Eoin

Nursing - in an Outpatient Procedures room for us. Similar question - are laboratory or haemovigilance (or biovigilance) involved in any way with autologous cell salvage & re-infusion? DON after us to get involved. So far we have stayed clear - apart from offering our expertise initially to help with SOP, setting up and validation of the process. Cheers Eoin

I'm with Malcolm. Seems we do things differently here on this side of the water. Units come with Compatibility and Traceability Tags and a Compatibility Report for the patient. If it hits the fan, they are responsible. Mind you, we do have an SLA. Also as part of ISO15189, the reference lab must be accredited (we get proof of their compliance(EQA etc and their registration)> Cheers, Eoin:cries:

Ah, you won't know yourself when you are computerised. With a good system, you will be able to see the stock fridge, freezer inventories etc. at a glance, and the full ready to Issue Inventory at another glance, with your patients listed and how many units, what type, expiry etc all available. Embrace and enjoy the change. Cheers Eoin

We get the BloodTrack system we use to generate a Compatibility and Traceability Label (two part). On both are the Unit No, group and expiry date. The compatibility goes into the Prescription & Management Document in the Patient Notes. The Traceability Label comes back to the lab as hard evidence of fating of the units (has to be kept for 30 years under EU legislation). The expiry date is also on the Compatibility Report - so plenty of places to be seen. Cheers Eoin

Used & kept in wards and OR. When new ones were ordered, I helped set a protocol for their validation - and let them at it. If pathology doesn't own it - I don't want to know about it, but the Haemovigilance Officer keeps an eye on revalidation checks etc. Cheers Eoin

Hi Justina, If you go to Library on toolbar at the top, choose BloodBank Talk Library, you will see numerous documents on Audits uploaded for use / modification. Cheers Eoin

We strike this occasionally. Since new EU regulations, remainder of the pack must be discarded at the four hour mark. We use packed red cells, so it is a rare patient that cannot tolerate a pack over four hours, especially if diuretics are co-administered. Anything outside this will generate a non-conformance. Had some physicians calling early on when new rule was enforced, but they accept it now and we rarely waste any leftovers in the pack. Cheers Eoin

HI Folks, No armband = no transfusion but - We use pre-op clinics as much as possible, as it allows better work flow and cuts down the pressure first am or late previous evening when patients present for ops. We keep the Typenex armband with the pre-op testing (all goes into the patient chart for admission). To get over the chain of identity (as nurses admitting and putting on the armband were not the same as the person taking the pre-op testing), we introduced a Patient & Typenex check form. It has a blurb about checking patient identity, but also has a space for the patient having the testing taken to sign. A typenex number is placed on this form also. On admission, the nurse checks the usual ID positively and also asks the patient to identify their signature. The nurse then signs on that form as indication that these checks have been carried out and the Typenex has been placed on the patient. We are shortly going to 2D armband coding (as we use BloodTrack Tx PDAs on the wards etc), placed on admission & we are considering doing away with Typenex. Have to think about this problem first though. I will attach a copy of the form we curently use FYI. Cheers Eoin

HI Folks, In Ireland, the recommendation is 1.50C. I think that comes from the National Haemovigilance Office. Obviously a rise of 1 or above you would be proactive in managing the patient anyway, but the lab comes into play when we get the 1.5 rise (or greater) with a workup due to possible Tx reaction . Cheers Eoin

Ah - we have all had frustrations like this. Sound like you need to have a multi-disciplinary team approach - then you can set projects which you convince them very cleverly are their ideas (that's the tricky bit), then they will be on-board and things will happen. Tracking the risk reduction with a FMEA analysis will also clearly demonstrate risk reduction with the process safety improvements (again - a team approach). Trying to bang it into their heads or holding a big stick over them (regulatory authorities) often is counter-productive (even though they sound like they need it). Sounds like a major disaster waiting to happen at the moment so doing nothing is not an option. Good luck with it. Cheers Eoin PS As I have said before, be very careful what you post on forums. Anonymise, anonymise.

Ah A lively debate - that's what we like. I would suggest that you must cut the pattern to suit the cloth. If you have a great supply and want to give them go for it (with the rider re the R1R1s below). I would have been jealous years ago of your O Neg supplies. Where I work now there is not as much a problem with O Negs, but years ago in the country areas in Australia, I would have been keeping the O Negs for obstetric patients, due to chronic shortages. We follow the British Guidelines as well (outlined by Malcolm). Here the O Negs we keep for emergency blood (uncrossed) is also CMV tested and Kell typed, so an extra cost there. I agree with Malcolm re O Negs to R1R1 patients (of whom I am also one). There are 17% odd of the Rh Pos (Caucasians), so that merits consideration as well. Maybe a good study for someone to follow up patients who were bleeding out (the survivors) - just to see how many develop antibodies and include how many have needed transfusions again over say 10 - 20 years post the trauma / massive haemorrhage. Cheers Eoin

We use Neoteric BloodTrack, both the manager mode in the lab, hooked to the blood transfusion PDA scanners in the ward. When armbands are produced, it has a 2D barcode (with 3 patient identifiers (name, DOB & medical record number) on it. When blood is issued for the patient, it has a compatibility label, plus a traceability label with all this info on it as well. At blood administration the nurse scans her ID (traceable), the patient 2d barcode (plus usual checks (Now have positive patient identification (PPI), and the unit number) - (variable ypes of barcode language can be used). It will then issue a GOOD visual and audible confirmation. By the way, they would only have got this far if when they scanned their ID, the patient barcode on the pick-up slip at a kiosk at the Issue Fridge and if there is blood for that patient, the door unlocks and they then choose the unit for the patient and scan the unit number. Again they will get the GOOD audible and visual signals. If it fails set rules (e,g, outside 72 hrs if previous units, unit has been out for of controlled refrigeration for more than 30 mins previously, wrong unit (wrong patient) or older unit in the fridge for that patient). We like it, the nurses like it - we consider it worth the money. Good luck with it Eoin

Hi Folks, In our system this is one non-conformance. When looking at system analysis (or root cause/s if you prefer) you would discover all the errors (we would classify as"missed chances to rectify" on this one) and they would be separately listed and risk assessed, using a matrix - as you seem to be doing - to set risk. James T. Reason of the University of Manchester Swiss Cheese theory showing how the barriers line up and the mistake goes through is interesting. Often errors are a number of small errors combined to create a bigger problem. If there are a lot of errors like this, it may be worth doing a "FMEA" (failure mode error analysis) on the system to see how robust it is. It never ceases to amaze me that just when you think a system is error proofed, along comes somebody to prove you wrong. Cheers Eoin

Hi Jill, We separate the plasmas (labelled and barcoded) at testing time for Group, Screen and holds. We can then pull and crossmatch when required (usual provisos of no antibodies, no pregnancy or transfusion in preceding three months). We will hold frozen (-30oC) for 30 days. Cheers Eoin :cool:

Our Hospital Information System generates op lists of planned surgery in advance (usually a week). They are pulled off by the Phlebotomy Department the day before and any not already collected are chased down by them. They know admission times for any late ins (including medicals by the way) and can chase them as well. I know the idea of not holding surgery depts hands all the time, but we find planned work-flow a whole heap better than lots of late urgent surprises. Works really well for us. Cheers Eoin

Hiho, Agree with all that has been said. We would wait the three days - abreviated testing after 10 units - why have a specimen full of who knows what? Cheers Eoin :cool:

I agree, I have made the point before in the BB Forum re a case about scientist negligence. If you are likely to be a witness or defendant (heaven help us) in any litigation, the less you post on public forums, the better. I was giving evidence on behalf of a laboratory I was manageing in Oz some years ago, and was amazed at the knowledge the defendant's brief had - still pondering where he got some of it. So please do be careful when discussing such cases - anonymise it to a suggested possible scenario if you like - ask a friend at another hospital distant from you to post it online and join the discussion if you like. Cheers Eoin :cool:

Hi John, Can be tricky little devils can't they? Have you contacted supplier re donor, giving sequence? My only addition to what has already been said is for an acute non-immune HTR - where the investigation does not reveal serologic abnormalities or misidentification errors (or haematuria for non-febrile haemolytic Tx reaction) is in most cases, a handling, storage, or transfusion error or malfunction that results in physical or chemical destruction of red cells. (Wrong giving set - other additives into line- saw one years ago where line was obviously heat affected - it had been draped over a central heater on the wall) Would be very interested in Follow-Up Cheers & good luck. Eoin

Heard of Dry Pubs in Australia, but never dry labs. I presume this means that the perpertrator of these acts is willing and knowlingly going outside laid down procedures (i.e. not performing required testing). Here he/she would be up before the professional body so fast his/her feet wouldn't touch the ground. Also your organisation should take immediate action. Any other comments I would have are unprintable. People like this we can well do without. As far as I am concerned this is a criminal negligance case. I do agree, you should be careful discussing it on an open forum however, as the perpertrator (won't use the word worker) does unfortunately have statutory legal rights as well. Cheers Eoin

Didn't get to San Diego, but Boston just across the pond for us so maybe next year? Would be interested in swapping stories re our "regulated haemovigilance" v/s your non-mandated "biovigilance". See you there maybe. Regards to all, Eoin

No problems here in Ireland either. Flushed direct to waste - once in diluted with plenty of other waste water etc. Cleared with Health & Safety Authorities. Remember there are small amounts of biological fluids going down also. Cheers Eoin