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Welcome to SIPI Connections, the podcast of the College of American Pathologists Council on Informatics and Pathology Innovation, also known as SIPI.
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Here we connect you with the leaders and committees shaping the future of pathology.
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I'm Dr.
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Emmy DeBacca, the Chair of SIPI.
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In this episode from our Horror Stories and Pathology Informatics series, Dr.
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Alexis Carter and Dr.
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Mandy O'Leary will be presenting Typos, Transfusions, and Trouble, the case of a delayed hemolytic transfusion reaction.
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Take it away, Dr.
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Carter.
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Hi, everyone.
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Welcome to Horror Stories and Pathology Informatics, Lessons Learned from Things Gone Awry, a series to help your healthcare organization.
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Number one, keep patients safe, and number two, avoid painful problems.
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I'm your host, Dr.
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Alexis Carter, a pathologist and the moderator for this series.
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And with me today is another pathologist, Dr.
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Mandy O'Leary.
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As a reminder, these podcasts are available from your favorite podcast service under SIPI Connections, that's C-I-P-I connections, and is also from the College of American Pathologists website at www.cap.org.
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Today's episode is Typos, Transfusions and Trouble: The Case of a Delayed Hemolytic Transfusion Reaction.
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As always, there's a few disclaimers needed before we get started.
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All of the situations discussed in this podcast are based on real events.
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So if any of our listeners think that the situation described can't or wouldn't happen, we can assure you that it can and did.
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Having said that, all information that could identify the personnel or the healthcare organization involved, not much less the patient, have been removed and replaced with fictitious characters and a fictitious location of Cabot Cove Memorial Hospital.
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Any locale-specific aspects, for example, regulations that are more specific than a national U.S.
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level have been removed, and some details regarding the situation which do not affect the main point of the event have been changed.
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Finally, the person presenting the failure is not the person who contributed it for a discussion.
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All of these things were done to ensure that we focus on the lessons learned so that we can help others avoid these mistakes.
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Of course, this podcast does not represent legal or medical advice, and the lessons learned may not account for specific barriers that may be present at your own organization.
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Okay, so now that we've done our disclaimers, let's get started.
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Again, here with me is Dr.
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Mandy O'Leary, who's going to present today's case called Typos Transfusions in Trouble, the case of a delayed hemolytic transfusion reaction, and the lessons learned from it.
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So, Dr.
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O'Leary, let's start with the basics of the failure that we're going to discuss today.
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What happened?
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Sure thing, Dr.
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Carter.
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Okay, so what we have in this case is a 16-year-old male patient with a history of sickle cell disease who presented to the Cabot Cove Memorial Hospital Emergency Department after developing severe body pain and difficulty breathing for the past 24 hours.
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When the emergency doctor saw him, the patient had hypotension on his vital signs and scleral ictaris on the physical exam.
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Scleral icterus means yellowing of the white part of your eyes.
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So the doctor ordered some labs to help discern what might be going on with the sickle cell disease.
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Lab testing showed a significant decrease in his hemoglobin level, down to 5.1 grams per deciliter, with associated reticulocytosis, indirect hyperbilarubinebia, and increased lactate dehydrogenase.
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The patient had reported that his hemoglobin normally ran around 8 grams per deciliter.
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So he was down about three points or three units in his hemoglobin level.
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So with these values in his history of sickle cell disease, the blood bank did some additional testing.
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First, a direct antiglobulin test was performed.
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This test is also known as the direct Coombs test.
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This would help identify if there were antibodies or complement bound to the red cell surfaces that were causing hemolysis.
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The DAT was reported as 2 plus positive on a scale of 1 to 4 plus, and the patient's antibody screen was also positive with anti-S antibodies showing on the antibody ID panel.
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So when the doctor went back to talk to the patient, the patient's mother mentioned that the patient had been hospitalized eight days ago to have his gallbladder removed for chola cystitis.
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He had been transfused two units of red blood cells prior to surgery to raise his hemoglobin level at that time.
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This raised the doctor's suspicion because he couldn't find anything in the patient's chart about this encounter.
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There were no op notes, no lab tests, no blood transfusion information, but the patient's mother insisted that the surgery had occurred at Cabot Cove Memorial Hospital where they were in the emergency department.
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So after scratching his head, the doctor asked for some further investigation, and that investigation revealed that the patient's name had been misspelled during registration for the colosystectomy eight days prior, and that a new patient record had been created at that time.
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This new medical record contained the documentation for the patient's recent hospitalization for the surgical procedure and the current encounter in the emergency department.
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Unfortunately, the new medical record which was created did not contain the patient's history of sickle cell disease, nor did it contain any prior history from blood bank testing, like his antibody history.
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When the doctor reviewed the type and screen testing for the pre-operative transfusion, there was no mention of the patient's previously identified anti-S antibody.
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And because of this, the blood he was given for the cholesteromy had not been screened for the S antigen or any of the other common antibodies like Big C, Big E, and Kel, which are commonly screened for when a patient has sickle cell disease.
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The current symptoms the patient had developed were due to a delayed hemolytic transfusion reaction because of an amnestic response, in other words, a late immune memory response to the big S antigen in the transfused red blood cells.
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Okay, well.
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So there's a lot to unpack here.
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And first, let's start with what do you think the fundamental contributing factor was to this particular error?
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Well, the big thing was the misspelling of the name.
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So when the patient presented for his admission for the cholesteromy eight days ago, he had been misregistered under a misspelled name.
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So his prior history from his original medical chart was not linked to his surgical hospital stay.
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So in this case, his transfusion history and antibody history were not present for the surgical team, and his medical record ended up being incomplete.
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So with the misspelling of his name, the laboratory didn't have access to the patient's prior transfusion history or historical type in screen results, and therefore had to rely on a current type-in screen to guide blood product selection.
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And certain antibodies, such as anti-big S, can wax and wane in intensity over time, and they may not be detected on a typen screen depending on the timing and nature of the sensitization event.
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So despite potentially eluding detection by a conventional type-in screen, the S antigen, which is an IgG antibody, can induce a rapid and vigorous immune response in the patient upon re-encountering the antigen characteristic of IgG antibodies.
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The result can be, as in this case, a delayed hemolytic reaction.
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Okay, so with regard to this issue, it sounds like uh this could have been completely avoided had the patient been properly registered, right?
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Completely avoided.
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Yeah, so that's that's the difficulty in this case.
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Um so what do you think could have been done?
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You know, patient registration can be a difficult thing, right?
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Registrars are dealing with a bunch of patients, uh, some of whom may have the same names or difficult to spell names.
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What do you think could have been done to help avoid or mitigate this issue?
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So accurate and unique patient identification in the care continuum is the cornerstone of patient care and safety, just like you you were referring to.
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As positive patient identification is essential to ensuring that the right patient receives the right care, we have to match clinical records for the correct patient.
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And that is core to ensuring safe, high-quality patient care.
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Ways to do this, use of technology such as touch screen tablets or patient registration kiosks that allow patients to verify their identity, update their personal information.
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These things actually reduce data entry errors.
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And then issues with incomplete or inaccessible patient history can also happen if there's a system downtime or if there's an implementation of a new piece of the lab system or the blood bank management system, if the previous data isn't converted to the new system prior to go live.
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So, in those cases, the laboratory has to have a dedicated downtime computer where they can access historical patient transfusion records during system outages or connectivity issues.
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Now, with all the cyber attacks and ransomware events that have been becoming more prevalent in healthcare, this is especially critical.
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An implementation of a new LIS or blood bank system must include a strategy for migrating patients' historical records and preserving access following the sunsetting of those legacy systems.
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Okay.
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So we've talked about the main uh the main problem or main error, but there's always, you know, there's the main contributor to an error, and then there's always secondary and sometimes even tertiary factors that can contribute.
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Um, these can include, you know, just inhibited communication, poor relationship silos between groups, there can be infrastructural issues.
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So, what kinds of secondary and tertiary issues do you think may have contributed to this particular error?
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In this case, there could have been delay in merging the patient records following the patient's surgical hospitalization from eight years, eight days ago, which hindered the investigation into the cause for the patient's transfusion reaction for delayed hemolytic anemia.
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Okay, so what do you think could have been done to prevent this delay in merging the patient's duplicate record?
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A lot of institutions actually have policies, Dr.
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Carter, against merging patient records while the patient's currently hospitalized and receiving care so that issues are avoided with ordering and resulting of imaging and lab tests.
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When you merge records, mistakes can be made, and hospitals want to make sure they're merging the appropriate records with the appropriate patient and that patient's results.
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If there's any overlap in the two records or same or similar numbers identifying certain information, that can also lead to problems with merging, and you won't necessarily know right away that a mistake's been made.
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So it's better to do that when the patient isn't in the hospital receiving care.
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There should, however, be an institutional policy for timely merging of duplicate records within an acceptable time frame.
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And this generally is out of laboratory's purview.
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Leaders within the laboratory should have awareness of the policy, but they may not always have input into the exact timing as it happens.
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Right.
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And merging of patient records becomes even more important when you're talking about blood bank history, right?
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Because, you know, knowing that the patient, for example, has had a prior bone marrow transplant or has leukemia or some of these other things is important because you're going to make different decisions about what products get made available to those patients.
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You know, for example, they're going to need to be irradiated, right, before the patient can get them.
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So let's talk first about the importance of registration.
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So, you know, patient registration errors do happen when patients get registered.
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It is, it is rare, but it does happen.
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And when it happens, you know, then you have missing history.
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You've got data that's missing.
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And in this case, because this patient's anti-S antibody was not on record for the blood bank, and his sickle cell history was not on record, because as you stated, sickle cell patients often have uh special units selected for them to prevent them from developing unnecessary antibodies, right?
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Because they get a lot of transfusions.
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Um, you know, what, you know, what do you think that patients can do to protect themselves in addition to, you know, sort of tablets and other things?
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I know that when I've gotten registered for the hospital myself, you know, they ask me to look at my armband, you know, and to make sure that everything is correct.
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What else do you think uh patients might be able to do to help protect themselves?
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So right, like they can look at their armband.
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I don't know about you, but when I go even just to a regular doctor's appointment these days, every single person I encounter on the staff, um, so every person that I encounter on the staff asks me, what's my name and date of birth?
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And I may answer that five or six times or even more times when I end up going to an appointment, and it gets a little repetitive, but I promise you they are doing that for patient safety reasons.
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Right.
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So they want to make sure they have you, the right patient that they're seeing and doing whatever procedure on.
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Other things they do are in surgeries or other procedures, they do timeouts where they take a pause and the medical staff make sure that they have identified the correct person, their date of birth, any other pertinent information, including the actual procedure they may be doing to that person.
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Because that's important.
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If someone's going into surgery, for example, and they put them under anesthesia, and you as the patient aren't able to answer because you've been knocked out, right?
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So that's something.
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For blood, specifically, what I advise people to do, especially on the blood center side, anytime you donate blood, the blood centers actually are testing you for your blood type and whether or not you do have antibodies present.
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And they usually I um they usually tell you if you do have antibodies.
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And I always, as a medical director of the blood center, would advise patients to get a medical alert bracelet that they could wear.
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For example, if you had diabetes, you might wear that or another disease.
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But to put that you have blood bank or that you have blood antibodies on your medical alert bracelet, because if you get in a car accident or something and you're taken to the hospital, you may or may not be conscious and you may or may not be able to answer people when they're asking you questions in the medical setting.
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So that's always important.
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Um, if you don't have a medical alert bracelet, some people put the information on cards in their wallets, but all of those are different options that can be pursued.
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Yeah, I agree.
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That's totally important.
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You know, other things, like if we have patients listening to the podcast, I would say, like, when they show you your armband or your label or whatever, make sure your name is correctly spelled.
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And it's not okay for it to be misspelled, right?
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You know, you need to insist that they get it right.
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Another thing that I do I have a tendency to do is like I insist that people label the lab tubes.
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They're drawing from me before they leave the room, and I check the labels to make sure that it's mine.
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Because, you know, you and I are both pathologists.
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We understand that there are labeling errors that happen, not, you know, they do happen.
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And um, and one of the patients can be their own best advocates when it comes to that.
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And while people may be like, I'm gonna label it correctly, well, that's great.
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I still want to see it.
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So so yeah, I don't think though most people are going to actually remember to have them label, but definitely you and I would do that.
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I know we would do that.
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So I would advocate for any patient to do that because you need you need to be sure that it's your stuff that's going through.
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Because as you said at the beginning of this podcast, if your identification is not correct in our system, nothing else that we do is gonna be right, right?
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Correct, you know, nothing else.
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The other thing too is I advise people to ask questions.
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Um, it's not uncommon that we switch blood types and products based on the availability of the products in the blood bank.
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And I've had instances where patients get freaked out because their blood type is A and the red cells that we hang are type O.
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We have done the testing in the lab and we've made sure that they are cross-match compatible for the patient.
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But if you see something that bothers you or is like ding, ding, ding, there's a problem here.
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Um, this isn't my blood type.
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I thought my blood type was A.
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Please ask the questions because we're always happy to answer.
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Yeah.
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And you never know when you might be able to pick something up that way.
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Um, I know we wanted to touch, um, so I want to take just a step back and talk about red cell antigens because you know, most patients and physicians are aware of blood groups A, B, and O, right, and A, B.
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Um, and they're aware of POS and neg.
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You know, they hear I'm APAS, I'm O neg, you know, what have you.
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But I don't think many people, probably outside of pathology, understand that red cells have a gazillion little antigens over their surface.
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And an antigen for, you know, lay people is it's either a protein or it can be a sugar that's sitting on the surface of the red cell.
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And um, so your body knows your own red cells, but if you get foreign red cells, and I had one colleague who used to refer to transfusions as blood transplants because um because he wanted people to take transfusions very seriously, um, that you're giving somebody a transplant of somebody else's blood.
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And so um, just like a solid organ transplant, patients can develop antibodies to these little surface proteins on red cells.
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Um uh talk to me a little bit about um, you know, these delayed hemolytic transfusion reactions, because because you know it's kind of scary.
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You do a type in screen where you're screening for all the antibodies that a patient might have to red cells and there's nothing there.
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And then all of a sudden you give somebody blood and wah-bang.
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And then worst case scenario, the the scenario that wakes me up in the middle of the night.
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So every time you are transfused, or when women are pregnant, for example, they are exposed to someone else's antigens and they can make antibodies themselves.
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And it may not be the very first time they're exposed.
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Um, they might make it on a subsequent exposure, but at some point, if somebody makes an antibody, then they're gonna have that for the rest of their life.
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It doesn't necessarily go away ever, it may decrease in strength or decrease in intensity, but it can come back rip-roaring when you're exposed to that antigen subsequently.
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So that's that amnestic response we had mentioned earlier.
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Um in this case, the patient had an anti-big S, and that's one of the IgG antibodies that can do that, is notorious for doing that.
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Um, so when the patient had the screen and they were getting the cholosystectomy, the antibody was so weak it didn't show up on the blood bank testing.
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But subsequently, when the patient was transfused on that admission, he got re-exposed to that, and his antibody came back, like I said, rip-roaring, ready to go and fight fight the antigen.
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So in that case, his cells, um, his immune system was attacking cells and it actually caused hemolysis of his red cells, and that's the delayed hemolytic reaction.
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You can have acute hemolytic reactions, which are really bad.
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Those usually happen with your IgM antibodies, but in this case, the S is an IgG and and therefore he ended up with a delayed reaction.
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Right.
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So this immune response, you know, just for for anyone who happens to be a uh, you know, a patient or a non-medical person listening, this immune response is incredibly useful, right?
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When we get exposed to viruses, for example, well, once we've seen a virus, and it's the same way, uh, same immune system response that we use when we're vaccinating people, you know, we make use of this incredible, you know, these immune system cells called B cells.
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Um, they make these little memory B cells that kind of sit there and percolate for like up to 20 years or more.
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Um, and they can, their whole job is to surveil for um foreign things coming in that you know your body doesn't like and then it will react to it.
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This is great when it comes to infections, not so much when you're trying to give somebody a much needed transfusion.
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Um so uh so it's all the same thing, and it's kind of um it's interesting.
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Um uh it's interesting how uh we do that.
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You know, as an informaticist, you know, I I work with, I'm not a blood banker myself, unlike you, but I uh I work with blood banks just because of, you know, identifying patients, making sure that we have uh the blood type history on file.
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So, you know, it's interesting because in blood bank, um, blood bank is really the only place that actually will get a sample on a patient and will test that sample and compare it to uh the blood type they had on any prior samples from the patient, right?
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Because they're looking for a mismatch.
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They're looking for the potential that somebody may have incorrectly labeled a sample.
00:21:50.720 --> 00:21:55.279
There's huge, you know, huge safety measures that we put into place for that.
00:21:55.759 --> 00:21:59.680
Um and uh so not having in this particular case that blood.
00:22:00.160 --> 00:22:10.960
blood bank history, um, you know, could have been problematic, not just from not having the anti-S history, but what if they had given gotten the wrong sample entirely, right?
00:22:11.119 --> 00:22:12.640
And it was a different blood type.
00:22:12.799 --> 00:22:20.079
That's where you can get your acute hemolytic transfusion reactions if you have an ABO incompatible transfusion.
00:22:20.319 --> 00:22:20.559
Yeah.
00:22:21.519 --> 00:22:21.759
Yeah.
00:22:21.839 --> 00:22:32.079
And those thankfully happen very rarely because of the processes that we put in place for patient safety, especially on the blood bank side.
00:22:32.319 --> 00:22:40.400
And we are actually required to do two types before we give a patient a specific blood type for that reason.
00:22:40.559 --> 00:22:49.680
We want to make sure that we're giving the right blood to the right person because if we do give the wrong blood, it can cause serious harm up to and including death, unfortunately.
00:22:49.920 --> 00:22:50.079
Right.
00:22:50.160 --> 00:22:52.240
And it's not just two separate samples, right?
00:22:52.319 --> 00:22:56.000
They have to be collected on two like at least 15 minutes from each other.
00:22:56.240 --> 00:23:04.480
You have to have two different nurses who are checking the patient's armband against the blood sample and signing it.
00:23:04.640 --> 00:23:13.119
You know, even when we do electronic positive patient ID, you have to have two nurses in most cases, although some there are some systems that will allow you to do one.
00:23:13.279 --> 00:23:16.000
I think the AABB will let you do one in some cases.
00:23:16.079 --> 00:23:26.640
But yeah, there's a lot, there's a lot of safety mechanisms that we put in place because doing an ABO incompatible transfusion, there's pretty high mortality rate associated with that, right?
00:23:26.799 --> 00:23:36.720
If you give somebody, for example, like I'm typo, so if somebody gives me A by mistake, then what's the risk that I'm not going to make it out of that?
00:23:37.680 --> 00:23:42.240
It's a it's a pretty high risk because you've got antibodies against A.
00:23:42.480 --> 00:23:46.160
Mm-hmm when I'm yeah right from Burrow.
00:23:46.480 --> 00:23:46.720
Yeah.
00:23:46.880 --> 00:23:49.279
It's not a case of exposure in that that case.
00:23:49.440 --> 00:23:49.599
Yeah.
00:23:50.000 --> 00:23:50.240
Right.
00:23:50.319 --> 00:23:59.839
And there's about 25 clinically significant antibodies besides ABO, in addition to that S that we were talking about, that we watch out for.
00:24:00.000 --> 00:24:03.519
And it it's an issue also when people become pregnant.
00:24:03.920 --> 00:24:10.240
It's actually a big reason of people having miscarriages because of antibodies that they have.
00:24:10.559 --> 00:24:10.799
Right.
00:24:11.039 --> 00:24:11.279
Yeah.
00:24:11.680 --> 00:24:34.880
So um so we did want to talk a little bit about there are some national efforts uh looking at um you know because in this particular case the patient showed up you know had a history at this hospital showed up to have the same hospital to have surgery then showed up you know in the emergency department afterward when they weren't feeling so good because they were having this delayed hemolytic transfusion reaction.
00:24:35.119 --> 00:24:48.000
And just I mean for people on the call um on the podcast a delayed hemolytic transfusion reaction my memory serves that it's it usually is defined by occurring seven to ten days after the transfusion is that correct?
00:24:48.319 --> 00:24:55.119
Yeah it can be as soon as two to three days depending on the strength of the antibody but up to up to two weeks or so after.
00:24:55.440 --> 00:24:55.680
Right.
00:24:55.839 --> 00:25:01.200
Whereas an acute an acute hemolytic transfusion reaction is immediate correct or pretty immediate.
00:25:01.680 --> 00:25:04.400
It's with yes pretty immediate or within hours.
00:25:04.720 --> 00:25:04.960
Right.
00:25:05.200 --> 00:25:05.519
Okay.
00:25:06.000 --> 00:26:04.000
So um but there is a a you know so this patient was all at the same organization right so the blood bank antibody history blood bank uh you know history file was all at that one organization only in this case because of the registration uh issues uh it wasn't accessible however we have patients go all over the place right I mean patients I know like um in the city where I live there's multiple major medical systems they don't share information between each other and so um so there have been efforts because blood bank antibody history can be so important because of the reactions that patients can have there are some national efforts to try to get a centralized repository of patient antibody history you want to talk about that a little bit sure so um this has been going on for 10 plus years but there was a a group of actually our colleagues um Dr.
00:26:04.079 --> 00:26:29.119
Carter who were working on this project a long time ago and they've made a lot of headway on it it was called alloantibody.org or is called alloantibody.org um they don't know if we're mentioning them in this podcast and CAP is not endorsing this by any means but they have made this national effort to make patient antibody information available across multiple regions or hospitals.
00:26:29.279 --> 00:26:54.480
So some of our electronic medical records allow us like if my hospital and your hospital are on the same electronic record we might be able to see each other's patient information if the patient's gone to both hospitals but not every hospital has the same electronic record information may vary from place to place and the blood centers might have information that isn't shared with the hospitals either.
00:26:54.799 --> 00:27:01.680
So these national registries are these big repositories where everyone can upload their data.
00:27:01.839 --> 00:27:39.839
And we're not saying that you would have to use or trust the result in there but if I had a patient who was first time patient to my facility and I was able to look in the registry and they had found antibodies on the patient before and I saw that those antibodies could be clinically significant as they could cause a hemolytic reaction of some sort then I could honor that antibody or I can make sure I do additional testing in my laboratory to see if that antibody exists just so that I'm not giving the patient blood that's positive for that antigen because that's what would cause the patient issues.
00:27:40.400 --> 00:28:03.680
So there, you know it's a safety measure to have that, especially you know, like you said in the city you're in in the cities where I've been and worked there are multiple hospitals and patients may go to multiple hospitals depending on which one's closest to them at the time they're having an incident especially if they're a sickle cell patient in crisis and they're in pain they need to get to somewhere fast to get care.
00:28:03.839 --> 00:28:06.319
So they're gonna go to whatever's closest.
00:28:06.640 --> 00:28:12.880
And that that hospital they go to might not be the same one that they normally go to and may not have all their information.
00:28:13.039 --> 00:28:15.440
So that's where this becomes very important.
00:28:15.680 --> 00:28:15.920
Right.
00:28:16.160 --> 00:28:22.640
The sharing of information in in this case is a really good thing for um for the patient themselves.
00:28:22.880 --> 00:28:42.400
So we're talking about doing additional testing um I do want to point out just in case we do have patients listening to this about you know well this all sounds great but what happens if I'm bleeding like stink from a car wreck you know uh are you gonna be like withholding blood from the emergency department if I need it.
00:28:42.799 --> 00:29:01.440
Oh absolutely not so we have ways um and there are blood types so O is considered the universal donor for red blood cells and in emergent situations we can release the O red blood cells for the emergency department to go ahead and transfuse the patient.
00:29:01.680 --> 00:29:19.680
We don't necessarily have time to test the other 25 plus clinically significant antibodies at that time but if we do give blood like that in an emergent situation to a patient the blood bank does go back after and complete that testing to make sure we don't have things like delayed hemolytic reactions.
00:29:20.000 --> 00:29:25.359
So the blood bank doctors and physicians are always keeping an eye on that.
00:29:25.680 --> 00:29:28.319
They can be called and we're on call 247.
00:29:28.640 --> 00:29:38.400
So anyone practicing transfusion medicine understands pathology call in that we're on call all the time because we are very concerned and serious about patient safety.
00:29:38.720 --> 00:29:39.039
Right.
00:29:39.279 --> 00:29:51.039
I mean so in the in the case of an acute bleed getting blood into the patient in that case is more important than you know worrying about the delayed hemolytic transfusion reaction that might happen later.
00:29:52.079 --> 00:30:04.960
And you do do testing so that if we know when may be coming, you know, then clinicians know and then they can prepare for that and their treatments available for patients who they think may undergo something like that.
00:30:06.000 --> 00:30:15.599
Yeah so I I think just mentioning that kind of stuff is is important because you know patients are like you know you can't you know you can't withhold blood.
00:30:15.680 --> 00:30:16.400
No, we don't do that.
00:30:16.640 --> 00:30:28.880
So one thing to note is while we can do emergency release blood, the safest thing to do for the patient is to give cross matched blood that's compatible for that particular person.
00:30:29.039 --> 00:30:41.839
And the safest thing is to allow us in the blood bank to finish all of the testing to make sure we have caught antibodies that we can catch and give the correct blood that would be negative for those antigens.
00:30:42.480 --> 00:30:44.079
That does take time.
00:30:44.400 --> 00:30:58.799
So physicians and healthcare providers and even the patients need to know you know we don't have a magic tree that blood grows on that we can just pick the type off and say here you go and you get it in five minutes like through the drive-thru window at the fast food place.
00:30:58.960 --> 00:31:06.400
So it can take hours depending on whether the patient does have antibodies or not to prepare the appropriate blood.
00:31:06.720 --> 00:31:10.880
And that's what we prefer to do in giving the safest products to the patients.
00:31:11.119 --> 00:31:14.640
Right when you when you have the luxury of time and being able to do that.
00:31:14.720 --> 00:31:15.039
Yeah.
00:31:15.279 --> 00:31:15.599
Right.
00:31:16.240 --> 00:31:39.119
Yeah I mean I still remember uh a long time ago being in a blood bank where we had a patient who had an anti little e mosaic antibody um and this is is an extremely extremely rare antibody there were only like two people in the country who also had this kind of blood type and so we were having to get frozen units from the Red Cross it was lovely.
00:31:40.079 --> 00:31:41.920
We did it for the patient it was all good.
00:31:42.079 --> 00:31:52.240
She was getting really good care it was just um you know those those are situations that again as a transfusion when you're dealing with transfusion medicine they can keep you up at night.
00:31:53.039 --> 00:32:36.319
I do I do want to talk a little bit about patient registration because in my work as an informaticist you know there there are certain jobs I think which they're so critically important but they're so undervalued just in medicine because it's it's a lower paid position there tends to be a high turnover rate um you know and I just for anybody who does patient registrations or for example phlebotomy and specimen processing right those those are two areas in the lab where we tend to have a higher turnover just because you know it's kind of more of a frontline job.
00:32:37.200 --> 00:32:56.480
But for any of those individuals who are listening I just want to say thank you thank you thank you for everything that you do and when you do it right because you do it right you know 99.99% of the time so um it's it's really it is a critically important job and unfortunately very undervalued I think sometimes in medicine which is unfortunate.
00:32:57.200 --> 00:33:10.480
Yeah and I a thousand percent agree with you on that because if things aren't labeled appropriately up front or if there's a mistake made early in the process it messes up everything down the line for the patient to get the right results.
00:33:10.640 --> 00:33:13.680
So it really is a true team effort taking care of patients.
00:33:13.920 --> 00:33:21.440
Yeah yeah and sometimes you know patient registration errors can happen uh not because of the registrar's fault, right?
00:33:21.519 --> 00:33:24.559
A patient can come in and present false identification.
00:33:24.799 --> 00:33:29.119
A common reason why that can happen is the patient doesn't have health insurance, for example.
00:33:29.200 --> 00:33:34.319
And so they come in posing as somebody else who does have health insurance in order to try to get their care covered.
00:33:34.400 --> 00:33:39.119
We've had um in my career I have had that I've seen that happen a couple of times.
00:33:39.440 --> 00:33:41.119
It's rare but it can happen.
00:33:42.559 --> 00:33:44.880
So we're reaching the end of the podcast.
00:33:45.039 --> 00:33:49.039
I do just want to reiterate uh we did talk about alloantibody.org and while Dr.
00:33:49.119 --> 00:34:12.960
O'Leary and I are certainly uh fans of this effort just because we know uh how significant it can be when you don't have access to medical history on patients and especially when they have red cell antibodies um we do just want to reiterate that the College of American pathologists does not endorse alloantibody.org it's not that they don't like it it's just that they you know haven't reviewed it and they're not endorsing it.
00:34:13.840 --> 00:34:19.360
And so I just want to be clear about that because this is a College of American Pathologists podcast.
00:34:19.519 --> 00:34:24.159
Okay, so this has been really educational so let's sum it up for the listeners.
00:34:24.320 --> 00:34:30.239
What main lessons are learned from this incident and what do you recommend that our listeners should do to prevent this from happening?
00:34:30.559 --> 00:34:41.840
Okay so in this case lack of access to the patient's prior transfusion history due to misregistration of the patient under a misspelled name resulted in this delayed hemolytic transfusion reaction.
00:34:42.079 --> 00:34:53.039
Having access to the patient's historical information is essential as antibody levels for some red cell antigens can vary and can't always reliably be detected on the type in screen.
00:34:53.440 --> 00:35:11.679
So technological solutions such as touchscreen tablets, patient registration kiosks, and even non-tech solutions like the patient medic bracelet I mentioned can help make sure that we've got the correct information on patients for registration and correct medical information in emergency situations.
00:35:12.000 --> 00:35:23.840
And lastly labs must have strategies in place for access to their historical patient information during downtimes and following implementations of new systems for LIS or blood bank.
00:35:24.159 --> 00:35:28.320
Right and and in as much as possible patients also need to advocate for themselves.
00:35:28.719 --> 00:35:32.320
The spelling of your name matters matters a lot.
00:35:33.039 --> 00:35:34.719
Okay great so thanks so much Dr.
00:35:34.800 --> 00:35:51.039
O'Leary for presenting today for our listeners we hope that you have found this podcast on typos, transfusions and trouble the case of a delayed hemolytic transfusion reaction helpful this podcast was produced by the College of American Pathologists and the content was produced by the College of American Pathologists Informatics Committee.
00:35:51.199 --> 00:35:56.880
The Informatics Committee always welcomes questions about the podcast as well as suggestions for future podcasts.
00:35:57.119 --> 00:36:08.800
If you would like to contribute an issue that happened to you and for instructions on how to anonymously contribute an educational issue and its lessons learned, please contact the committee at the email address listed in the show notes.
00:36:08.960 --> 00:36:15.360
Please do not send specifics on this issue to this email address uh like the patient's information please don't do that.
00:36:15.840 --> 00:36:20.639
We thank you so much for listening and put we look forward to sharing our next podcast with you soon.
00:36:20.800 --> 00:36:21.519
Bye-bye.
00:36:21.920 --> 00:36:22.480
Thank you Dr.
00:36:22.559 --> 00:36:23.280
Carter and Dr.
00:36:23.360 --> 00:36:27.360
O'Leary for sharing this case and the lessons you learned from things gone awry.
00:36:27.679 --> 00:36:29.760
Thank you listeners for being here.
00:36:30.000 --> 00:36:38.400
Please stay tuned for future horror stories in pathology informatics and join us again for insights, updates and the people behind the innovation.
00:36:38.800 --> 00:36:43.039
This has been Sippy Connections where ideas meet action in pathology
00:00:00.640 --> 00:00:08.320
Welcome to SIPI Connections, the podcast of the College of American Pathologists Council on Informatics and Pathology Innovation, also known as SIPI.
00:00:08.640 --> 00:00:12.480
Here we connect you with the leaders and committees shaping the future of pathology.
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I'm Dr.
00:00:14.880 --> 00:00:16.879
Emmy DeBacca, the Chair of SIPI.
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In this episode from our Horror Stories and Pathology Informatics series, Dr.
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Alexis Carter and Dr.
00:00:23.440 --> 00:00:30.399
Mandy O'Leary will be presenting Typos, Transfusions, and Trouble, the case of a delayed hemolytic transfusion reaction.
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Take it away, Dr.
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Carter.
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Hi, everyone.
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Welcome to Horror Stories and Pathology Informatics, Lessons Learned from Things Gone Awry, a series to help your healthcare organization.
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Number one, keep patients safe, and number two, avoid painful problems.
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I'm your host, Dr.
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Alexis Carter, a pathologist and the moderator for this series.
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And with me today is another pathologist, Dr.
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Mandy O'Leary.
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As a reminder, these podcasts are available from your favorite podcast service under SIPI Connections, that's C-I-P-I connections, and is also from the College of American Pathologists website at www.cap.org.
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Today's episode is Typos, Transfusions and Trouble: The Case of a Delayed Hemolytic Transfusion Reaction.
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As always, there's a few disclaimers needed before we get started.
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All of the situations discussed in this podcast are based on real events.
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So if any of our listeners think that the situation described can't or wouldn't happen, we can assure you that it can and did.
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Having said that, all information that could identify the personnel or the healthcare organization involved, not much less the patient, have been removed and replaced with fictitious characters and a fictitious location of Cabot Cove Memorial Hospital.
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Any locale-specific aspects, for example, regulations that are more specific than a national U.S.
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level have been removed, and some details regarding the situation which do not affect the main point of the event have been changed.
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Finally, the person presenting the failure is not the person who contributed it for a discussion.
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All of these things were done to ensure that we focus on the lessons learned so that we can help others avoid these mistakes.
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Of course, this podcast does not represent legal or medical advice, and the lessons learned may not account for specific barriers that may be present at your own organization.
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Okay, so now that we've done our disclaimers, let's get started.
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Again, here with me is Dr.
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Mandy O'Leary, who's going to present today's case called Typos Transfusions in Trouble, the case of a delayed hemolytic transfusion reaction, and the lessons learned from it.
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So, Dr.
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O'Leary, let's start with the basics of the failure that we're going to discuss today.
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What happened?
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Sure thing, Dr.
00:02:41.120 --> 00:02:41.520
Carter.
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Okay, so what we have in this case is a 16-year-old male patient with a history of sickle cell disease who presented to the Cabot Cove Memorial Hospital Emergency Department after developing severe body pain and difficulty breathing for the past 24 hours.
00:02:57.439 --> 00:03:04.719
When the emergency doctor saw him, the patient had hypotension on his vital signs and scleral ictaris on the physical exam.
00:03:04.879 --> 00:03:08.879
Scleral icterus means yellowing of the white part of your eyes.
00:03:09.120 --> 00:03:14.159
So the doctor ordered some labs to help discern what might be going on with the sickle cell disease.
00:03:14.479 --> 00:03:30.319
Lab testing showed a significant decrease in his hemoglobin level, down to 5.1 grams per deciliter, with associated reticulocytosis, indirect hyperbilarubinebia, and increased lactate dehydrogenase.
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The patient had reported that his hemoglobin normally ran around 8 grams per deciliter.
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So he was down about three points or three units in his hemoglobin level.
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So with these values in his history of sickle cell disease, the blood bank did some additional testing.
00:03:47.120 --> 00:03:49.759
First, a direct antiglobulin test was performed.
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This test is also known as the direct Coombs test.
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This would help identify if there were antibodies or complement bound to the red cell surfaces that were causing hemolysis.
00:03:59.120 --> 00:04:10.240
The DAT was reported as 2 plus positive on a scale of 1 to 4 plus, and the patient's antibody screen was also positive with anti-S antibodies showing on the antibody ID panel.
00:04:10.560 --> 00:04:19.759
So when the doctor went back to talk to the patient, the patient's mother mentioned that the patient had been hospitalized eight days ago to have his gallbladder removed for chola cystitis.
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He had been transfused two units of red blood cells prior to surgery to raise his hemoglobin level at that time.
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This raised the doctor's suspicion because he couldn't find anything in the patient's chart about this encounter.
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There were no op notes, no lab tests, no blood transfusion information, but the patient's mother insisted that the surgery had occurred at Cabot Cove Memorial Hospital where they were in the emergency department.
00:04:45.279 --> 00:05:00.560
So after scratching his head, the doctor asked for some further investigation, and that investigation revealed that the patient's name had been misspelled during registration for the colosystectomy eight days prior, and that a new patient record had been created at that time.
00:05:00.879 --> 00:05:11.040
This new medical record contained the documentation for the patient's recent hospitalization for the surgical procedure and the current encounter in the emergency department.
00:05:11.360 --> 00:05:23.759
Unfortunately, the new medical record which was created did not contain the patient's history of sickle cell disease, nor did it contain any prior history from blood bank testing, like his antibody history.
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When the doctor reviewed the type and screen testing for the pre-operative transfusion, there was no mention of the patient's previously identified anti-S antibody.
00:05:33.120 --> 00:05:47.199
And because of this, the blood he was given for the cholesteromy had not been screened for the S antigen or any of the other common antibodies like Big C, Big E, and Kel, which are commonly screened for when a patient has sickle cell disease.
00:05:47.519 --> 00:06:00.720
The current symptoms the patient had developed were due to a delayed hemolytic transfusion reaction because of an amnestic response, in other words, a late immune memory response to the big S antigen in the transfused red blood cells.
00:06:02.079 --> 00:06:02.399
Okay, well.
00:06:02.560 --> 00:06:04.000
So there's a lot to unpack here.
00:06:04.240 --> 00:06:10.079
And first, let's start with what do you think the fundamental contributing factor was to this particular error?
00:06:10.639 --> 00:06:12.879
Well, the big thing was the misspelling of the name.
00:06:12.959 --> 00:06:20.879
So when the patient presented for his admission for the cholesteromy eight days ago, he had been misregistered under a misspelled name.
00:06:21.040 --> 00:06:27.120
So his prior history from his original medical chart was not linked to his surgical hospital stay.
00:06:27.279 --> 00:06:36.079
So in this case, his transfusion history and antibody history were not present for the surgical team, and his medical record ended up being incomplete.
00:06:36.319 --> 00:06:50.639
So with the misspelling of his name, the laboratory didn't have access to the patient's prior transfusion history or historical type in screen results, and therefore had to rely on a current type-in screen to guide blood product selection.
00:06:51.199 --> 00:07:03.040
And certain antibodies, such as anti-big S, can wax and wane in intensity over time, and they may not be detected on a typen screen depending on the timing and nature of the sensitization event.
00:07:03.279 --> 00:07:18.879
So despite potentially eluding detection by a conventional type-in screen, the S antigen, which is an IgG antibody, can induce a rapid and vigorous immune response in the patient upon re-encountering the antigen characteristic of IgG antibodies.
00:07:19.120 --> 00:07:23.759
The result can be, as in this case, a delayed hemolytic reaction.
00:07:24.480 --> 00:07:34.079
Okay, so with regard to this issue, it sounds like uh this could have been completely avoided had the patient been properly registered, right?
00:07:34.720 --> 00:07:36.079
Completely avoided.
00:07:36.399 --> 00:07:39.199
Yeah, so that's that's the difficulty in this case.
00:07:39.360 --> 00:07:43.839
Um so what do you think could have been done?
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You know, patient registration can be a difficult thing, right?
00:07:47.120 --> 00:07:52.480
Registrars are dealing with a bunch of patients, uh, some of whom may have the same names or difficult to spell names.
00:07:52.639 --> 00:07:56.079
What do you think could have been done to help avoid or mitigate this issue?
00:07:56.639 --> 00:08:06.560
So accurate and unique patient identification in the care continuum is the cornerstone of patient care and safety, just like you you were referring to.
00:08:06.720 --> 00:08:15.839
As positive patient identification is essential to ensuring that the right patient receives the right care, we have to match clinical records for the correct patient.
00:08:16.000 --> 00:08:19.519
And that is core to ensuring safe, high-quality patient care.
00:08:19.839 --> 00:08:29.839
Ways to do this, use of technology such as touch screen tablets or patient registration kiosks that allow patients to verify their identity, update their personal information.
00:08:30.079 --> 00:08:33.039
These things actually reduce data entry errors.
00:08:33.279 --> 00:08:50.720
And then issues with incomplete or inaccessible patient history can also happen if there's a system downtime or if there's an implementation of a new piece of the lab system or the blood bank management system, if the previous data isn't converted to the new system prior to go live.
00:08:50.960 --> 00:09:02.000
So, in those cases, the laboratory has to have a dedicated downtime computer where they can access historical patient transfusion records during system outages or connectivity issues.
00:09:02.559 --> 00:09:09.759
Now, with all the cyber attacks and ransomware events that have been becoming more prevalent in healthcare, this is especially critical.
00:09:10.000 --> 00:09:21.519
An implementation of a new LIS or blood bank system must include a strategy for migrating patients' historical records and preserving access following the sunsetting of those legacy systems.
00:09:21.919 --> 00:09:22.240
Okay.
00:09:22.559 --> 00:09:34.879
So we've talked about the main uh the main problem or main error, but there's always, you know, there's the main contributor to an error, and then there's always secondary and sometimes even tertiary factors that can contribute.
00:09:35.039 --> 00:09:42.799
Um, these can include, you know, just inhibited communication, poor relationship silos between groups, there can be infrastructural issues.
00:09:43.039 --> 00:09:48.320
So, what kinds of secondary and tertiary issues do you think may have contributed to this particular error?
00:09:48.639 --> 00:10:03.200
In this case, there could have been delay in merging the patient records following the patient's surgical hospitalization from eight years, eight days ago, which hindered the investigation into the cause for the patient's transfusion reaction for delayed hemolytic anemia.
00:10:03.519 --> 00:10:11.120
Okay, so what do you think could have been done to prevent this delay in merging the patient's duplicate record?
00:10:11.759 --> 00:10:14.720
A lot of institutions actually have policies, Dr.
00:10:14.879 --> 00:10:25.679
Carter, against merging patient records while the patient's currently hospitalized and receiving care so that issues are avoided with ordering and resulting of imaging and lab tests.
00:10:25.919 --> 00:10:35.919
When you merge records, mistakes can be made, and hospitals want to make sure they're merging the appropriate records with the appropriate patient and that patient's results.
00:10:36.159 --> 00:10:47.200
If there's any overlap in the two records or same or similar numbers identifying certain information, that can also lead to problems with merging, and you won't necessarily know right away that a mistake's been made.
00:10:47.360 --> 00:10:51.679
So it's better to do that when the patient isn't in the hospital receiving care.
00:10:51.919 --> 00:10:59.039
There should, however, be an institutional policy for timely merging of duplicate records within an acceptable time frame.
00:10:59.360 --> 00:11:02.879
And this generally is out of laboratory's purview.
00:11:03.039 --> 00:11:11.039
Leaders within the laboratory should have awareness of the policy, but they may not always have input into the exact timing as it happens.
00:11:11.440 --> 00:11:11.600
Right.
00:11:11.679 --> 00:11:17.600
And merging of patient records becomes even more important when you're talking about blood bank history, right?
00:11:17.840 --> 00:11:32.960
Because, you know, knowing that the patient, for example, has had a prior bone marrow transplant or has leukemia or some of these other things is important because you're going to make different decisions about what products get made available to those patients.
00:11:34.960 --> 00:11:39.519
You know, for example, they're going to need to be irradiated, right, before the patient can get them.
00:11:40.320 --> 00:11:45.519
So let's talk first about the importance of registration.
00:11:46.240 --> 00:11:52.159
So, you know, patient registration errors do happen when patients get registered.
00:11:52.240 --> 00:11:54.559
It is, it is rare, but it does happen.
00:11:54.720 --> 00:11:58.399
And when it happens, you know, then you have missing history.
00:11:58.559 --> 00:11:59.759
You've got data that's missing.
00:11:59.840 --> 00:12:18.320
And in this case, because this patient's anti-S antibody was not on record for the blood bank, and his sickle cell history was not on record, because as you stated, sickle cell patients often have uh special units selected for them to prevent them from developing unnecessary antibodies, right?
00:12:18.559 --> 00:12:20.639
Because they get a lot of transfusions.
00:12:20.879 --> 00:12:30.399
Um, you know, what, you know, what do you think that patients can do to protect themselves in addition to, you know, sort of tablets and other things?
00:12:30.559 --> 00:12:38.639
I know that when I've gotten registered for the hospital myself, you know, they ask me to look at my armband, you know, and to make sure that everything is correct.
00:12:38.799 --> 00:12:43.279
What else do you think uh patients might be able to do to help protect themselves?
00:12:43.759 --> 00:12:46.159
So right, like they can look at their armband.
00:12:46.320 --> 00:13:01.039
I don't know about you, but when I go even just to a regular doctor's appointment these days, every single person I encounter on the staff, um, so every person that I encounter on the staff asks me, what's my name and date of birth?
00:13:01.279 --> 00:13:12.320
And I may answer that five or six times or even more times when I end up going to an appointment, and it gets a little repetitive, but I promise you they are doing that for patient safety reasons.
00:13:12.399 --> 00:13:12.559
Right.
00:13:12.720 --> 00:13:19.679
So they want to make sure they have you, the right patient that they're seeing and doing whatever procedure on.
00:13:19.840 --> 00:13:39.840
Other things they do are in surgeries or other procedures, they do timeouts where they take a pause and the medical staff make sure that they have identified the correct person, their date of birth, any other pertinent information, including the actual procedure they may be doing to that person.
00:13:40.000 --> 00:13:40.960
Because that's important.
00:13:41.039 --> 00:13:49.840
If someone's going into surgery, for example, and they put them under anesthesia, and you as the patient aren't able to answer because you've been knocked out, right?
00:13:50.320 --> 00:13:51.679
So that's something.
00:13:52.000 --> 00:14:07.679
For blood, specifically, what I advise people to do, especially on the blood center side, anytime you donate blood, the blood centers actually are testing you for your blood type and whether or not you do have antibodies present.
00:14:07.840 --> 00:14:13.279
And they usually I um they usually tell you if you do have antibodies.
00:14:13.440 --> 00:14:21.039
And I always, as a medical director of the blood center, would advise patients to get a medical alert bracelet that they could wear.
00:14:21.200 --> 00:14:25.759
For example, if you had diabetes, you might wear that or another disease.
00:14:26.000 --> 00:14:43.679
But to put that you have blood bank or that you have blood antibodies on your medical alert bracelet, because if you get in a car accident or something and you're taken to the hospital, you may or may not be conscious and you may or may not be able to answer people when they're asking you questions in the medical setting.
00:14:43.919 --> 00:14:45.519
So that's always important.
00:14:45.679 --> 00:14:54.399
Um, if you don't have a medical alert bracelet, some people put the information on cards in their wallets, but all of those are different options that can be pursued.
00:14:54.639 --> 00:14:55.519
Yeah, I agree.
00:14:55.600 --> 00:14:56.799
That's totally important.
00:14:57.039 --> 00:15:05.519
You know, other things, like if we have patients listening to the podcast, I would say, like, when they show you your armband or your label or whatever, make sure your name is correctly spelled.
00:15:05.600 --> 00:15:08.000
And it's not okay for it to be misspelled, right?
00:15:08.080 --> 00:15:10.399
You know, you need to insist that they get it right.
00:15:10.720 --> 00:15:16.080
Another thing that I do I have a tendency to do is like I insist that people label the lab tubes.
00:15:16.240 --> 00:15:21.600
They're drawing from me before they leave the room, and I check the labels to make sure that it's mine.
00:15:21.759 --> 00:15:23.840
Because, you know, you and I are both pathologists.
00:15:24.000 --> 00:15:30.720
We understand that there are labeling errors that happen, not, you know, they do happen.
00:15:30.879 --> 00:15:36.080
And um, and one of the patients can be their own best advocates when it comes to that.
00:15:36.240 --> 00:15:40.080
And while people may be like, I'm gonna label it correctly, well, that's great.
00:15:40.240 --> 00:15:41.360
I still want to see it.
00:15:41.519 --> 00:15:49.679
So so yeah, I don't think though most people are going to actually remember to have them label, but definitely you and I would do that.
00:15:49.759 --> 00:15:50.720
I know we would do that.
00:15:51.039 --> 00:15:56.639
So I would advocate for any patient to do that because you need you need to be sure that it's your stuff that's going through.
00:15:56.720 --> 00:16:07.600
Because as you said at the beginning of this podcast, if your identification is not correct in our system, nothing else that we do is gonna be right, right?
00:16:07.840 --> 00:16:09.039
Correct, you know, nothing else.
00:16:09.440 --> 00:16:12.799
The other thing too is I advise people to ask questions.
00:16:12.960 --> 00:16:20.240
Um, it's not uncommon that we switch blood types and products based on the availability of the products in the blood bank.
00:16:20.320 --> 00:16:28.639
And I've had instances where patients get freaked out because their blood type is A and the red cells that we hang are type O.
00:16:28.879 --> 00:16:34.639
We have done the testing in the lab and we've made sure that they are cross-match compatible for the patient.
00:16:34.879 --> 00:16:39.919
But if you see something that bothers you or is like ding, ding, ding, there's a problem here.
00:16:40.080 --> 00:16:41.679
Um, this isn't my blood type.
00:16:41.759 --> 00:16:43.279
I thought my blood type was A.
00:16:43.440 --> 00:16:47.039
Please ask the questions because we're always happy to answer.
00:16:47.279 --> 00:16:47.519
Yeah.
00:16:47.679 --> 00:16:50.879
And you never know when you might be able to pick something up that way.
00:16:51.039 --> 00:17:04.079
Um, I know we wanted to touch, um, so I want to take just a step back and talk about red cell antigens because you know, most patients and physicians are aware of blood groups A, B, and O, right, and A, B.
00:17:04.400 --> 00:17:06.160
Um, and they're aware of POS and neg.
00:17:06.400 --> 00:17:09.279
You know, they hear I'm APAS, I'm O neg, you know, what have you.
00:17:09.440 --> 00:17:18.000
But I don't think many people, probably outside of pathology, understand that red cells have a gazillion little antigens over their surface.
00:17:18.079 --> 00:17:26.480
And an antigen for, you know, lay people is it's either a protein or it can be a sugar that's sitting on the surface of the red cell.
00:17:26.720 --> 00:17:45.119
And um, so your body knows your own red cells, but if you get foreign red cells, and I had one colleague who used to refer to transfusions as blood transplants because um because he wanted people to take transfusions very seriously, um, that you're giving somebody a transplant of somebody else's blood.
00:17:45.200 --> 00:17:53.039
And so um, just like a solid organ transplant, patients can develop antibodies to these little surface proteins on red cells.
00:17:53.279 --> 00:18:03.920
Um uh talk to me a little bit about um, you know, these delayed hemolytic transfusion reactions, because because you know it's kind of scary.
00:18:04.000 --> 00:18:10.559
You do a type in screen where you're screening for all the antibodies that a patient might have to red cells and there's nothing there.
00:18:10.720 --> 00:18:14.799
And then all of a sudden you give somebody blood and wah-bang.
00:18:16.799 --> 00:18:21.839
And then worst case scenario, the the scenario that wakes me up in the middle of the night.
00:18:22.160 --> 00:18:35.279
So every time you are transfused, or when women are pregnant, for example, they are exposed to someone else's antigens and they can make antibodies themselves.
00:18:35.519 --> 00:18:39.599
And it may not be the very first time they're exposed.
00:18:39.759 --> 00:18:49.680
Um, they might make it on a subsequent exposure, but at some point, if somebody makes an antibody, then they're gonna have that for the rest of their life.
00:18:49.920 --> 00:19:05.359
It doesn't necessarily go away ever, it may decrease in strength or decrease in intensity, but it can come back rip-roaring when you're exposed to that antigen subsequently.
00:19:05.599 --> 00:19:08.960
So that's that amnestic response we had mentioned earlier.
00:19:09.680 --> 00:19:22.000
Um in this case, the patient had an anti-big S, and that's one of the IgG antibodies that can do that, is notorious for doing that.
00:19:22.240 --> 00:19:33.680
Um, so when the patient had the screen and they were getting the cholosystectomy, the antibody was so weak it didn't show up on the blood bank testing.
00:19:34.160 --> 00:19:47.920
But subsequently, when the patient was transfused on that admission, he got re-exposed to that, and his antibody came back, like I said, rip-roaring, ready to go and fight fight the antigen.
00:19:48.319 --> 00:19:59.839
So in that case, his cells, um, his immune system was attacking cells and it actually caused hemolysis of his red cells, and that's the delayed hemolytic reaction.
00:20:00.319 --> 00:20:03.839
You can have acute hemolytic reactions, which are really bad.
00:20:04.000 --> 00:20:13.039
Those usually happen with your IgM antibodies, but in this case, the S is an IgG and and therefore he ended up with a delayed reaction.
00:20:13.440 --> 00:20:13.920
Right.
00:20:14.160 --> 00:20:23.839
So this immune response, you know, just for for anyone who happens to be a uh, you know, a patient or a non-medical person listening, this immune response is incredibly useful, right?
00:20:23.920 --> 00:20:37.519
When we get exposed to viruses, for example, well, once we've seen a virus, and it's the same way, uh, same immune system response that we use when we're vaccinating people, you know, we make use of this incredible, you know, these immune system cells called B cells.
00:20:37.599 --> 00:20:43.839
Um, they make these little memory B cells that kind of sit there and percolate for like up to 20 years or more.
00:20:44.079 --> 00:20:55.039
Um, and they can, their whole job is to surveil for um foreign things coming in that you know your body doesn't like and then it will react to it.
00:20:55.279 --> 00:21:02.880
This is great when it comes to infections, not so much when you're trying to give somebody a much needed transfusion.
00:21:03.039 --> 00:21:08.400
Um so uh so it's all the same thing, and it's kind of um it's interesting.
00:21:08.559 --> 00:21:11.599
Um uh it's interesting how uh we do that.
00:21:11.759 --> 00:21:26.400
You know, as an informaticist, you know, I I work with, I'm not a blood banker myself, unlike you, but I uh I work with blood banks just because of, you know, identifying patients, making sure that we have uh the blood type history on file.
00:21:26.480 --> 00:21:43.039
So, you know, it's interesting because in blood bank, um, blood bank is really the only place that actually will get a sample on a patient and will test that sample and compare it to uh the blood type they had on any prior samples from the patient, right?
00:21:43.359 --> 00:21:45.519
Because they're looking for a mismatch.
00:21:45.599 --> 00:21:50.559
They're looking for the potential that somebody may have incorrectly labeled a sample.
00:21:50.720 --> 00:21:55.279
There's huge, you know, huge safety measures that we put into place for that.
00:21:55.759 --> 00:21:59.680
Um and uh so not having in this particular case that blood.
00:22:00.160 --> 00:22:10.960
blood bank history, um, you know, could have been problematic, not just from not having the anti-S history, but what if they had given gotten the wrong sample entirely, right?
00:22:11.119 --> 00:22:12.640
And it was a different blood type.
00:22:12.799 --> 00:22:20.079
That's where you can get your acute hemolytic transfusion reactions if you have an ABO incompatible transfusion.
00:22:20.319 --> 00:22:20.559
Yeah.
00:22:21.519 --> 00:22:21.759
Yeah.
00:22:21.839 --> 00:22:32.079
And those thankfully happen very rarely because of the processes that we put in place for patient safety, especially on the blood bank side.
00:22:32.319 --> 00:22:40.400
And we are actually required to do two types before we give a patient a specific blood type for that reason.
00:22:40.559 --> 00:22:49.680
We want to make sure that we're giving the right blood to the right person because if we do give the wrong blood, it can cause serious harm up to and including death, unfortunately.
00:22:49.920 --> 00:22:50.079
Right.
00:22:50.160 --> 00:22:52.240
And it's not just two separate samples, right?
00:22:52.319 --> 00:22:56.000
They have to be collected on two like at least 15 minutes from each other.
00:22:56.240 --> 00:23:04.480
You have to have two different nurses who are checking the patient's armband against the blood sample and signing it.
00:23:04.640 --> 00:23:13.119
You know, even when we do electronic positive patient ID, you have to have two nurses in most cases, although some there are some systems that will allow you to do one.
00:23:13.279 --> 00:23:16.000
I think the AABB will let you do one in some cases.
00:23:16.079 --> 00:23:26.640
But yeah, there's a lot, there's a lot of safety mechanisms that we put in place because doing an ABO incompatible transfusion, there's pretty high mortality rate associated with that, right?
00:23:26.799 --> 00:23:36.720
If you give somebody, for example, like I'm typo, so if somebody gives me A by mistake, then what's the risk that I'm not going to make it out of that?
00:23:37.680 --> 00:23:42.240
It's a it's a pretty high risk because you've got antibodies against A.
00:23:42.480 --> 00:23:46.160
Mm-hmm when I'm yeah right from Burrow.
00:23:46.480 --> 00:23:46.720
Yeah.
00:23:46.880 --> 00:23:49.279
It's not a case of exposure in that that case.
00:23:49.440 --> 00:23:49.599
Yeah.
00:23:50.000 --> 00:23:50.240
Right.
00:23:50.319 --> 00:23:59.839
And there's about 25 clinically significant antibodies besides ABO, in addition to that S that we were talking about, that we watch out for.
00:24:00.000 --> 00:24:03.519
And it it's an issue also when people become pregnant.
00:24:03.920 --> 00:24:10.240
It's actually a big reason of people having miscarriages because of antibodies that they have.
00:24:10.559 --> 00:24:10.799
Right.
00:24:11.039 --> 00:24:11.279
Yeah.
00:24:11.680 --> 00:24:34.880
So um so we did want to talk a little bit about there are some national efforts uh looking at um you know because in this particular case the patient showed up you know had a history at this hospital showed up to have the same hospital to have surgery then showed up you know in the emergency department afterward when they weren't feeling so good because they were having this delayed hemolytic transfusion reaction.
00:24:35.119 --> 00:24:48.000
And just I mean for people on the call um on the podcast a delayed hemolytic transfusion reaction my memory serves that it's it usually is defined by occurring seven to ten days after the transfusion is that correct?
00:24:48.319 --> 00:24:55.119
Yeah it can be as soon as two to three days depending on the strength of the antibody but up to up to two weeks or so after.
00:24:55.440 --> 00:24:55.680
Right.
00:24:55.839 --> 00:25:01.200
Whereas an acute an acute hemolytic transfusion reaction is immediate correct or pretty immediate.
00:25:01.680 --> 00:25:04.400
It's with yes pretty immediate or within hours.
00:25:04.720 --> 00:25:04.960
Right.
00:25:05.200 --> 00:25:05.519
Okay.
00:25:06.000 --> 00:26:04.000
So um but there is a a you know so this patient was all at the same organization right so the blood bank antibody history blood bank uh you know history file was all at that one organization only in this case because of the registration uh issues uh it wasn't accessible however we have patients go all over the place right I mean patients I know like um in the city where I live there's multiple major medical systems they don't share information between each other and so um so there have been efforts because blood bank antibody history can be so important because of the reactions that patients can have there are some national efforts to try to get a centralized repository of patient antibody history you want to talk about that a little bit sure so um this has been going on for 10 plus years but there was a a group of actually our colleagues um Dr.
00:26:04.079 --> 00:26:29.119
Carter who were working on this project a long time ago and they've made a lot of headway on it it was called alloantibody.org or is called alloantibody.org um they don't know if we're mentioning them in this podcast and CAP is not endorsing this by any means but they have made this national effort to make patient antibody information available across multiple regions or hospitals.
00:26:29.279 --> 00:26:54.480
So some of our electronic medical records allow us like if my hospital and your hospital are on the same electronic record we might be able to see each other's patient information if the patient's gone to both hospitals but not every hospital has the same electronic record information may vary from place to place and the blood centers might have information that isn't shared with the hospitals either.
00:26:54.799 --> 00:27:01.680
So these national registries are these big repositories where everyone can upload their data.
00:27:01.839 --> 00:27:39.839
And we're not saying that you would have to use or trust the result in there but if I had a patient who was first time patient to my facility and I was able to look in the registry and they had found antibodies on the patient before and I saw that those antibodies could be clinically significant as they could cause a hemolytic reaction of some sort then I could honor that antibody or I can make sure I do additional testing in my laboratory to see if that antibody exists just so that I'm not giving the patient blood that's positive for that antigen because that's what would cause the patient issues.
00:27:40.400 --> 00:28:03.680
So there, you know it's a safety measure to have that, especially you know, like you said in the city you're in in the cities where I've been and worked there are multiple hospitals and patients may go to multiple hospitals depending on which one's closest to them at the time they're having an incident especially if they're a sickle cell patient in crisis and they're in pain they need to get to somewhere fast to get care.
00:28:03.839 --> 00:28:06.319
So they're gonna go to whatever's closest.
00:28:06.640 --> 00:28:12.880
And that that hospital they go to might not be the same one that they normally go to and may not have all their information.
00:28:13.039 --> 00:28:15.440
So that's where this becomes very important.
00:28:15.680 --> 00:28:15.920
Right.
00:28:16.160 --> 00:28:22.640
The sharing of information in in this case is a really good thing for um for the patient themselves.
00:28:22.880 --> 00:28:42.400
So we're talking about doing additional testing um I do want to point out just in case we do have patients listening to this about you know well this all sounds great but what happens if I'm bleeding like stink from a car wreck you know uh are you gonna be like withholding blood from the emergency department if I need it.
00:28:42.799 --> 00:29:01.440
Oh absolutely not so we have ways um and there are blood types so O is considered the universal donor for red blood cells and in emergent situations we can release the O red blood cells for the emergency department to go ahead and transfuse the patient.
00:29:01.680 --> 00:29:19.680
We don't necessarily have time to test the other 25 plus clinically significant antibodies at that time but if we do give blood like that in an emergent situation to a patient the blood bank does go back after and complete that testing to make sure we don't have things like delayed hemolytic reactions.
00:29:20.000 --> 00:29:25.359
So the blood bank doctors and physicians are always keeping an eye on that.
00:29:25.680 --> 00:29:28.319
They can be called and we're on call 247.
00:29:28.640 --> 00:29:38.400
So anyone practicing transfusion medicine understands pathology call in that we're on call all the time because we are very concerned and serious about patient safety.
00:29:38.720 --> 00:29:39.039
Right.
00:29:39.279 --> 00:29:51.039
I mean so in the in the case of an acute bleed getting blood into the patient in that case is more important than you know worrying about the delayed hemolytic transfusion reaction that might happen later.
00:29:52.079 --> 00:30:04.960
And you do do testing so that if we know when may be coming, you know, then clinicians know and then they can prepare for that and their treatments available for patients who they think may undergo something like that.
00:30:06.000 --> 00:30:15.599
Yeah so I I think just mentioning that kind of stuff is is important because you know patients are like you know you can't you know you can't withhold blood.
00:30:15.680 --> 00:30:16.400
No, we don't do that.
00:30:16.640 --> 00:30:28.880
So one thing to note is while we can do emergency release blood, the safest thing to do for the patient is to give cross matched blood that's compatible for that particular person.
00:30:29.039 --> 00:30:41.839
And the safest thing is to allow us in the blood bank to finish all of the testing to make sure we have caught antibodies that we can catch and give the correct blood that would be negative for those antigens.
00:30:42.480 --> 00:30:44.079
That does take time.
00:30:44.400 --> 00:30:58.799
So physicians and healthcare providers and even the patients need to know you know we don't have a magic tree that blood grows on that we can just pick the type off and say here you go and you get it in five minutes like through the drive-thru window at the fast food place.
00:30:58.960 --> 00:31:06.400
So it can take hours depending on whether the patient does have antibodies or not to prepare the appropriate blood.
00:31:06.720 --> 00:31:10.880
And that's what we prefer to do in giving the safest products to the patients.
00:31:11.119 --> 00:31:14.640
Right when you when you have the luxury of time and being able to do that.
00:31:14.720 --> 00:31:15.039
Yeah.
00:31:15.279 --> 00:31:15.599
Right.
00:31:16.240 --> 00:31:39.119
Yeah I mean I still remember uh a long time ago being in a blood bank where we had a patient who had an anti little e mosaic antibody um and this is is an extremely extremely rare antibody there were only like two people in the country who also had this kind of blood type and so we were having to get frozen units from the Red Cross it was lovely.
00:31:40.079 --> 00:31:41.920
We did it for the patient it was all good.
00:31:42.079 --> 00:31:52.240
She was getting really good care it was just um you know those those are situations that again as a transfusion when you're dealing with transfusion medicine they can keep you up at night.
00:31:53.039 --> 00:32:36.319
I do I do want to talk a little bit about patient registration because in my work as an informaticist you know there there are certain jobs I think which they're so critically important but they're so undervalued just in medicine because it's it's a lower paid position there tends to be a high turnover rate um you know and I just for anybody who does patient registrations or for example phlebotomy and specimen processing right those those are two areas in the lab where we tend to have a higher turnover just because you know it's kind of more of a frontline job.
00:32:37.200 --> 00:32:56.480
But for any of those individuals who are listening I just want to say thank you thank you thank you for everything that you do and when you do it right because you do it right you know 99.99% of the time so um it's it's really it is a critically important job and unfortunately very undervalued I think sometimes in medicine which is unfortunate.
00:32:57.200 --> 00:33:10.480
Yeah and I a thousand percent agree with you on that because if things aren't labeled appropriately up front or if there's a mistake made early in the process it messes up everything down the line for the patient to get the right results.
00:33:10.640 --> 00:33:13.680
So it really is a true team effort taking care of patients.
00:33:13.920 --> 00:33:21.440
Yeah yeah and sometimes you know patient registration errors can happen uh not because of the registrar's fault, right?
00:33:21.519 --> 00:33:24.559
A patient can come in and present false identification.
00:33:24.799 --> 00:33:29.119
A common reason why that can happen is the patient doesn't have health insurance, for example.
00:33:29.200 --> 00:33:34.319
And so they come in posing as somebody else who does have health insurance in order to try to get their care covered.
00:33:34.400 --> 00:33:39.119
We've had um in my career I have had that I've seen that happen a couple of times.
00:33:39.440 --> 00:33:41.119
It's rare but it can happen.
00:33:42.559 --> 00:33:44.880
So we're reaching the end of the podcast.
00:33:45.039 --> 00:33:49.039
I do just want to reiterate uh we did talk about alloantibody.org and while Dr.
00:33:49.119 --> 00:34:12.960
O'Leary and I are certainly uh fans of this effort just because we know uh how significant it can be when you don't have access to medical history on patients and especially when they have red cell antibodies um we do just want to reiterate that the College of American pathologists does not endorse alloantibody.org it's not that they don't like it it's just that they you know haven't reviewed it and they're not endorsing it.
00:34:13.840 --> 00:34:19.360
And so I just want to be clear about that because this is a College of American Pathologists podcast.
00:34:19.519 --> 00:34:24.159
Okay, so this has been really educational so let's sum it up for the listeners.
00:34:24.320 --> 00:34:30.239
What main lessons are learned from this incident and what do you recommend that our listeners should do to prevent this from happening?
00:34:30.559 --> 00:34:41.840
Okay so in this case lack of access to the patient's prior transfusion history due to misregistration of the patient under a misspelled name resulted in this delayed hemolytic transfusion reaction.
00:34:42.079 --> 00:34:53.039
Having access to the patient's historical information is essential as antibody levels for some red cell antigens can vary and can't always reliably be detected on the type in screen.
00:34:53.440 --> 00:35:11.679
So technological solutions such as touchscreen tablets, patient registration kiosks, and even non-tech solutions like the patient medic bracelet I mentioned can help make sure that we've got the correct information on patients for registration and correct medical information in emergency situations.
00:35:12.000 --> 00:35:23.840
And lastly labs must have strategies in place for access to their historical patient information during downtimes and following implementations of new systems for LIS or blood bank.
00:35:24.159 --> 00:35:28.320
Right and and in as much as possible patients also need to advocate for themselves.
00:35:28.719 --> 00:35:32.320
The spelling of your name matters matters a lot.
00:35:33.039 --> 00:35:34.719
Okay great so thanks so much Dr.
00:35:34.800 --> 00:35:51.039
O'Leary for presenting today for our listeners we hope that you have found this podcast on typos, transfusions and trouble the case of a delayed hemolytic transfusion reaction helpful this podcast was produced by the College of American Pathologists and the content was produced by the College of American Pathologists Informatics Committee.
00:35:51.199 --> 00:35:56.880
The Informatics Committee always welcomes questions about the podcast as well as suggestions for future podcasts.
00:35:57.119 --> 00:36:08.800
If you would like to contribute an issue that happened to you and for instructions on how to anonymously contribute an educational issue and its lessons learned, please contact the committee at the email address listed in the show notes.
00:36:08.960 --> 00:36:15.360
Please do not send specifics on this issue to this email address uh like the patient's information please don't do that.
00:36:15.840 --> 00:36:20.639
We thank you so much for listening and put we look forward to sharing our next podcast with you soon.
00:36:20.800 --> 00:36:21.519
Bye-bye.
00:36:21.920 --> 00:36:22.480
Thank you Dr.
00:36:22.559 --> 00:36:23.280
Carter and Dr.
00:36:23.360 --> 00:36:27.360
O'Leary for sharing this case and the lessons you learned from things gone awry.
00:36:27.679 --> 00:36:29.760
Thank you listeners for being here.
00:36:30.000 --> 00:36:38.400
Please stay tuned for future horror stories in pathology informatics and join us again for insights, updates and the people behind the innovation.
00:36:38.800 --> 00:36:43.039
This has been Sippy Connections where ideas meet action in pathology
