I am reviewing CAP TRM.40820 regarding history checks on perinatal samples.

Currently, we are not doing this on our prenatal samples. My staff groans at the thought due to our high volume. However, I am beginning to think we should. What is the consensus out there? Thanks in advance for your replies.

I do not interpret this checklist item to imply that this search must be done by BB/Lab personnel. I think it is more appropriate that the obstetrical nurses (or nurses of the obstetrician's office) perform this check of all pregnant patients by reviewing previous records and lab data.

You can't control what the nurses in the obstetrician offices do, but could you work with the nurses in your OB Dept to routine check the patients' records and previous lab data whenever the patient is admitted? (Perhaps add a blank on OB pts'' admission paperwork to document the ABO/Rh?)

Anyplace I have ever worked, we checked records on all samples submitted to blood bank.

I used to work in an outpatient "reference" lab where we performed up to 300 type and screens a day. We did have a process to check the historical antibody identifications and ABO discrepancies, but I don't know how we would have been able to check the historical types on those patients. In the hospital setting , we do check our hospital records on all Blood Bank samples.

I entirely agree with David.

Even if you should detect an antibody that was known to be present in a previous pregnancy, the history may be important.

For example, we have recently dealt with a first sample in pregnancy in a third pregnancy from a lady with anti-D. The referring hospital was different from that in the previous pregnancy. The first sample this time gave an anti-D level of 3.8IU/mL (in other words, unlikely to cause clinically significant HDNF). However, towards the end of the previous pregnancy, the anti-D had risen to a level of 25IU/mL (very likely to cause clinically significant HDNF). We were able, therefore, to include this fact in the report on the present sample, which would act as a "heads up" for the Obstetrician looking after the new pregnancy that very close monitoring would be in order.

If you are a high-volume blood bank, you probably have a computer system that has built-in historical checking of all patients at results entry. We acknowledge that we viewed the history (usually blank) by resulting "yes" in the History Checked? field. If a flag appears, we view the history file information and respond accordingly.

Our main problem is not antibodies, but Weak D's. While we call them Rh Neg now, a previous history may show them as Rh Pos. We also have a rather high percentage of OB patients using someone else's insurance, so there is the occasional ABO/Rh discrepancy.

The only sample we did not perform and document a history check on was a cord blood sample.

I am reviewing CAP TRM.40820 regarding history checks on perinatal samples.

Currently, we are not doing this on our prenatal samples. My staff groans at the thought due to our high volume. However, I am beginning to think we should. What is the consensus out there? Thanks in advance for your replies.

We do. I think you need to if you are CAP accredited. And regardless, I think it is good practice.

The only sample we did not perform and document a history check on was a cord blood sample.

Strangely, I've never worked in an institution that does John!!!!!!!!!!

Mind you, if the cord ABO and Rh is identical to Mum's, we would test the cord sample with NaOH, just to be on the safe side (and I know this is not foolproof, particularly if Mum has a high HbF level herself).

Time Out........

Yes, our computer automatically checks all current ABO/Rh results against pts' ABO/Rh previous results and alerts us if the results do not match. (Our computer records go back almost 20 years.) So that is not a problem for those of us who have a computer system.

Am I the only one that thinks the CAP checklist item refers to checking for ABO/Rh testing for each pregnant patient (not just the pregnant patients that have current Blood Bank testing ordered)? In other words, we (in our Blood Bank) don't always know if a patient is pregnant, we often don't have access to their prenatal testing (done by a reference lab), we don't handle Rh-Immune Globulin (it is issued by our Pharmancy Dept.), etc. So our Blood Bank Dept is not in a good position to oversee this important patient care issue.

I think this checklist item dictates that your institution must have some policy/procedure in place that guarantees that the OB (and Emergency Dept) personnel check the ABO/Rh results (and administers Rh-Immune Globulin appropriately) if a patient is pregnant. (Am I a "Lone Ranger" with this interpretation of CAP's intent?)

John - you are right (of course); we don't even make a patient card for cord bloods.

Time Out........

Yes, our computer automatically checks all current ABO/Rh results against pts' ABO/Rh previous results and alerts us if the results do not match. (Our computer records go back almost 20 years.) So that is not a problem for those of us who have a computer system.

Am I the only one that thinks the CAP checklist item refers to checking for ABO/Rh testing for each pregnant patient (not just the pregnant patients that have current Blood Bank testing ordered)? In other words, we (in our Blood Bank) don't always know if a patient is pregnant, we often don't have access to their prenatal testing (done by a reference lab), we don't handle Rh-Immune Globulin (it is issued by our Pharmancy Dept.), etc. So our Blood Bank Dept is not in a good position to oversee this important patient care issue.

I think this checklist item dictates that your institution must have some policy/procedure in place that guarantees that the OB (and Emergency Dept) personnel check the ABO/Rh results (and administers Rh-Immune Globulin appropriately) if a patient is pregnant. (Am I a "Lone Ranger" with this interpretation of CAP's intent?)

I think you may in fact be the Lone Ranger on this one. If you look at the note on the question:

TRM.40820

Phase II

N/A YES NO

Is there a method to ensure that laboratory records for ABO/Rh testing are searched for each pregnant patient for at least the preceding 12 months?

NOTE: The purpose of this comparison is to detectsample/patient identification errors or other errors that might lead to the attribution of an incorrect blood type or antibody screen result to a pregnant patient; this might result in a missed opportunity to provide prophylaxis against or appropriate treatment for perinatal alloimmunization. If the laboratory performing the testing does not maintain records that would allow this check to be performed, the testing shall be reported with a disclaimer alerting the ordering physician that the check has not been performed and that such verifications of the sample's identity and the test results are strongly recommended.

(Coloring mine)

It appears to reference the laboratory checking the records to ensure that the testing reported is on the correct patient. They must report the test results with a disclaimer if they cannot do the record check.

We, too, check a history in our computer for every sample submitted except for cord bloods.

adiescast - I appreciate your response. Yes, I've read CAP's note that follows the checklist item, and I accept that I'm probably reading more into this item than anyone else. My concern involves those OB and miscarriage patients who do not have any Blood Bank work currently ordered, so it's up to OB or ER personnel to have a policy in place to check the patients' records and make sure Rh-Immune Globulin is administered appropriately. (If only this were a perfect world.......)

Too true...that would obviously be the ideal. I think many OB offices are actually pretty much in tune with that need. It's the ERs that I would be more concerned about. Fortunately, it can be rectified next day if the OB is called in. The lab doesn't have much control over those situations unless a sample is submitted, at which point, the records are (by policy) reviewed and the point is moot. I don't think in this case that CAP is expecting the lab to police the situations under which no sample is submitted.

We report a history check on all samples. Yes, or No histrory. Our computer will generate a QA failure if the history ABO/Rh is not identical to current. The history also shows previous antibody ID, antigen typings, or special instructions, such as issuing a PALL leukoreduction filter or giving phenotype specific on sickle patients.

Too true...that would obviously be the ideal. I think many OB offices are actually pretty much in tune with that need. It's the ERs that I would be more concerned about. Fortunately, it can be rectified next day if the OB is called in. The lab doesn't have much control over those situations unless a sample is submitted, at which point, the records are (by policy) reviewed and the point is moot. I don't think in this case that CAP is expecting the lab to police the situations under which no sample is submitted.

Actually, I was almost cited during a CAP inspection for not having a mechanism in place to check types on all possible pregnant patients, whether a sample was submitted or not, especially the ER. The thing that saved me was that I asked (very sweetly, of course ), "That's a big problem for us! Can you recommend a good way to tackle it?" He hemmed and hawed and then didn't cited us. Our inspectors, you see, were from a VA hospital with a population of 95% old men :tongue:. He had never worked at a facility that had OB patients, so he had never had to worry about that item. After we talked things over, he decided it was problem he was glad to be without.

Ann -

I love it!! Your approach to interacting with inspectors can be very effective....Don't argue, don't be defensive, but try to solicit a suggestion for a realistic solution. You may just get a good suggestion.....Or, more likely, it may become obvious that there isn't a realistic solution. (We need to share this approach with our less experienced supervisors, especially those who tend to "flip out" during inspections.)

Couldn't agree more.

Make them sweat too!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Edited October 12, 200915 yr by Malcolm Needs

We were reviewing this checklist requirement today during our self inspection process and it sparked a discussion:

 

At our institution we do a history check with all type and screen specimens.

For patients with no previous history we reflex a Retype specimen request.

In the event of an outpatient OB patient, we are unable to do the Retype, so the reflex order is cancelled.

Should we be including a disclaimer comment that our process to reduce misidentification errors has not been performed as it is described at the end of the note for this checklist item: "disclaimer alerting the ordering physician that the check has not been performed and that such verifications of the sample's identity and the test results are strongly recommended."

We check all histories (our system requires it prior to any testing).

The scariest is just a few weeks ago where there were duplicate records on the same patient (one with antibodies and one without). Current sample antibody screen= neg.

We had units crossmatched before we realized this but luckily had not issued any, and released the units in time.

We check every sample by name to avoid these types of issues.

Your approach to interacting with inspectors can be very effective....Don't argue, don't be defensive------really true!....      

We were reviewing this checklist requirement today during our self inspection process and it sparked a discussion:

 

At our institution we do a history check with all type and screen specimens.

For patients with no previous history we reflex a Retype specimen request.

In the event of an outpatient OB patient, we are unable to do the Retype, so the reflex order is cancelled.

Should we be including a disclaimer comment that our process to reduce misidentification errors has not been performed as it is described at the end of the note for this checklist item: "disclaimer alerting the ordering physician that the check has not been performed and that such verifications of the sample's identity and the test results are strongly recommended."

We have same process. Enter disclaimer.

The only sample we did not perform and document a history check on was a cord blood sample.

Actually, we don't check on them either - just like Malcolm says - I never have anyplace.

We check for previous record on all specimens except for cord blood samples (which we check the mothers on). We cannot accept reports from physician offices.....I have an entire stack of incorrect ABO/Rh results on OB patients. Not that we would accept them in the first place.