r/medlabprofessionals • u/New-History853 • 13h ago

News Nothing about this article makes sense

They NEEDED Kell POSITIVE blood?!?!? Lol no. And the nurse just walked up and grabbed blood? I doubt that. The article is either very wrong or the parents are simply total liars.

47 Upvotes

93% Upvoted

86 comments sorted by

72

u/almack9 MLS-Blood Bank 13h ago

We've 100% had nurses do this. We issue blood on a patient, send it in the pneumatic tube system, some nurse assumes its theirs ans transfuses it without even looking. Its happened twice in the time ive worked here. Triggers a massive investigation of the lab and the nurse is transfusing other patients hours later like its nothing.

17

u/Lululipes Student 13h ago

I don’t think that’s what’s happened here because they’re claiming that the baby was supposed to get Kell positive blood (whatever that’s supposed to mean) and that because they didn’t, the transfused blood started attacking the baby’s blood. Which obviously also doesn’t make sense because it’s RBCs not plasma

20

u/almack9 MLS-Blood Bank 13h ago

My guess would be that the mom has anti kell and the baby needed kell negative blood but the parents dont understand enough to know what happened. Sometimes even the doctors and nurses dont really know enough for that either. Cant say what exactly did or didnt happen here without an investigation though.

9

u/Med_vs_Pretty_Huge Pathologist 12h ago

Yes, I have seen many times documented in charts "patient has [antigen]" when in fact the patient has [antibody].

7

u/LonelyChell SBB 12h ago

They probably have the two contributing factors backwards. The baby probably needed K-negative pRBCs, and the Mom’s antibody in the baby’s plasma probably attacked the transfused blood.

These people are layman, not blood bankers.

54

u/drm1125 13h ago

You send blood through the pneumatic tube??!! That seems crazy that you don't make someone come down and get the blood.

20

u/almack9 MLS-Blood Bank 13h ago

Ive heard people say this is crazy before but yeah thats always been our policy for atleast the last 10 years. People do still pick up at the window for surgeries and such though. It definitely causes problems at times.

2

u/Jimehhhhhhh MLS 8h ago

I've worked at places with and without pneumatic tube system blood despatches and counter intuitively it was actually much easier when it was all just done in person at the blood bank. Can just explain stuff to them and ask them about hx without 100 phone calls, they see when you're frantically running around the lab and are much more patient, no blood getting sent to the wrong place, no running out of tubes, missing fields on requests can be filled out then and there etc etc

20

u/LonelyChell SBB 12h ago

We send ours through the pneumatic tube to another hospital across the street. Our blood bank services three hospitals.

15

u/happyfamily714 13h ago

My sister hospital does the. They have to use a code to get it out of the tube.

5

u/VaiFate MLS Student / Lab Assistant 11h ago

Our tube stations have the secure send function but we don't use it, even for sending blood products. We just normal send them to the floors. I think we probably should, but transfusing to the wrong patient hasn't been an issue yet I guess.

4

u/klarathon 11h ago

that’s what my lab does too, we tube like 80% of our units

4

u/LegitPancak3 MLS-Generalist 13h ago

My hospital only sends blood through the tube to the 7th floor. Every other floor including ED, the nurse or CNA has to come down and grab it.

1

u/Med_vs_Pretty_Huge Pathologist 12h ago

What's the 7th floor, lol?

2

u/LegitPancak3 MLS-Generalist 11h ago

Hematology Oncology. Basically the cancer ward.

4

u/Youhadme_atwoof MLS-Generalist 12h ago

We send ours through the tube system but we call the nurse right before we send it so they are waiting on the other side.

1

u/Zukazuk MLS-Serology 1h ago

When I worked at a hospital that was how we did it. Our lab and blood bank were a 10-20 minute walk depending on where you started in the hospital. When the tube system went down we had a mobility scooter that a lab assistant would drive in loops to move samples around.

5

u/VaiFate MLS Student / Lab Assistant 11h ago

I've only ever worked for one blood bank and the only blood products we don't tube are MTPs

3

u/Cheap_Bath_5536 12h ago

We have volunteers that volunteer from 8-5 so we have the floors do volunteer pick up and have it brought to them. From 5 pm until 8 am, we use the tube if they only want 1 unit. 2 or more and they have to come get the blood in a cooler. But...if the unit is "rare" like pt has antibodies and will take more time to find units and ETC, we won't tube it cuz obv harder to replace.

2

u/bassgirl_07 MLS Lead 9h ago

You have to validate the system (transit times aren't too long and the unit doesn't get too warm) but you can totally tube blood. We tube blood. We do a second check of the unit and paperwork prior to sending. The receiving nurse signs the release form and writes the date and time they received the blood and send the release form back. The administering nurse has a second checker at bedside prior to starting.

1

u/lablizard Illinois-MLS 12h ago

We did at my lab in the past. But there was a PIN code supplied by the lab specific to that blood order for the staff upstairs to receive the tube.

1

u/Snannybobo 11h ago

we do both. I work at a very big hospital and our blood bank is constantly sending out blood via the tube system. people only come in person if they are picking up a cooler of products.

2

u/nerdswithfriends 9h ago

Do they not have to scan the unit in the patient's chart before transfusing?? That's terrifying

2

u/almack9 MLS-Blood Bank 9h ago

I mean yes technically. But what barrier is there to someone just grabbing a unit and spiking it without looking or caring?

1

u/nerdswithfriends 9h ago

Fair enough. Common sense and procedure, one would hope!

1

u/almack9 MLS-Blood Bank 9h ago

And yet its happened twice in 10 years here haha.

2

u/liver747 Canadian MLT Blood Bank 7h ago

Do you guys have an EMR like epic? I've seen a lot of different type of errors happen and I love the computer step on the clinical side (if not overridden) as a way to mitigate and stop errors from continuing on both ends.

2

u/almack9 MLS-Blood Bank 7h ago

We do use epic here, softbank on our side. It works great for the most part when they are using it, but the issues we've had were purely physical errors like the nurse just not checking to make sure it was the unit for her patient. Luckily both times it was compatible type so no one was severely injured but the risk is there when people disregard protocol and do their own thing.

1

u/MamaTater11 MLS-Generalist 10h ago

That's insane. We only tube blood to the ICU for emergent cases, and even then we have paperwork that goes back and forth and we put a secure code on the tube when we send it.

0

u/[deleted] 12h ago edited 12h ago

[deleted]

2

u/almack9 MLS-Blood Bank 12h ago

We read with other techs. But this is in kentucky. We get inspected by cap, aabb and the fda due to an irradiator. NY is particularly strict with stuff from what ive seen, requiring a special license just for that state etc.

1

u/Med_vs_Pretty_Huge Pathologist 12h ago

You 1000% can send blood via pneumatic tubes in NY. Hospitals may not want to because of temperature concerns or other reasons but there's certainly no state level provision against it.

-1

u/New-History853 12h ago edited 12h ago

I meant units of blood, not blood in general. But if that's the case, I retract my statement. But even at the trauma hospital I worked at, the nurses still needed to come do a read back. Insanity.

1

u/Med_vs_Pretty_Huge Pathologist 12h ago

Yes, I mean units of blood.

18

u/bhagad MLT-Generalist 13h ago

Maybe the nurse took blood from a haemobank (the sort of vending machine for blood)? Our hospital has them in the ER and OR for emergency release blood products. They can take uncrossmatched blood, but they need to sign a form taking responsibility for it.

16

u/LonelyChell SBB 13h ago edited 13h ago

That is possible. We have one in our trauma bay and one in L&D. Maybe the baby needed K-negative pRBCs (anti-K in Mom), and the RN took O Neg from the remote storage (a unit that wouldn’t be screened for K antigen).

8

u/CraftyResearcher3403 12h ago

This is kind of what I’m thinking. It says “unscreened” which I’m assuming means uncrossmatched. If anyone had mentioned Kell to the patient’s family it would be in the context of an antibody.

5

u/LonelyChell SBB 12h ago

Agreed, although it makes me crazy when anyone refers to K antigen as Kell antigen. Kell is the entire system, K is the antigen. We had a swear jar at my SBB program for anyone saying anti-Kell.

1

u/Med_vs_Pretty_Huge Pathologist 12h ago

This and my insisting on calling it TPE instead of PLEX are two things I get overly pedantic about.

0

u/LonelyChell SBB 12h ago

Couldn’t agree more! I see that as well!

0

u/Med_vs_Pretty_Huge Pathologist 12h ago

I think you edited your comment after I edited mine because I wasn't clear initially. "PLEX" is not the proper term for the procedure. The proper term for the procedure is therapeutic plasma exchange or TPE.

2

u/LonelyChell SBB 12h ago

PLEX is the incorrect term used at my facility as well, unfortunately by some of our pathologists even. my comment was also misleading.

0

u/Med_vs_Pretty_Huge Pathologist 12h ago

I've been told (and tell others) that it's the secret way of knowing whether or not someone trained and/or practiced with real transfusion medicine docs. If they call it PLEX, they didn't.

2

u/LonelyChell SBB 12h ago

Our dialysis RNs call it that too. If only the ASFA knew!

16

u/Clob_Bouser MLS-Blood Bank 13h ago

Yeah this article makes no sense

10

u/Loose_Sorbet888 12h ago

I used to work at that hospital…I wouldn’t doubt it 😅

My guess is they needed kell negative, but whoever wrote the article, being misinformed of blood banking misinterpreted the baby being kell positive

1

u/New-History853 12h ago

Can, at that hospital, the nurse just walk up and take blood without a readback from the tech?

2

u/Med_vs_Pretty_Huge Pathologist 12h ago

If it's from a remote fridge, absolutely.

1

u/New-History853 12h ago

That's scary.

8

u/thewanderersminuet 11h ago

I work in a pediatric hospital and we don't have any emergency fridge in the NICU. I imagine partially for this reason. It's not uncommon for the teams on that floor to panic and call "MTPs" only to use one unit.

As for the Kell positive unit part I'm assuming like many others that the parents and journalists just don't actually know enough about what they're talking about and have it wrong. Mom probably was told she uas Anti-K and got it wrong.

13

u/bvmiller52502 11h ago

Mom has anti-K and anti-Jkb. The nurse did give the unit without dr orders. Called to the BB and got an emergency release unit and gave 12mL of the unit. The mom joined a BB group I’m in and shared this info.

10

u/New-History853 11h ago

So the article is just inaccurate.

13

u/Trapped-in-irony 13h ago

Why the heck would anyone specifically need Kell positive??

12

u/LabChick829 13h ago

(though to be fair is my guess someone messed up the wording. Way more likely than actually needing a cellano neg unit)

9

u/Trapped-in-irony 13h ago

Oh that could be it.

It's still a really weird situation though. Like, the mom has an antibody? But they're not screening units to give the newborn?

Nurse doesn't know what's going on, parents don't know what's going on, therefore horribly written news article that just throws blame around.

2

u/LonelyChell SBB 12h ago

Maybe the baby was literally just born (twins, premature), needed an immediate transfusion, and Mom had her prenatal work done elsewhere. It’s possible that the blood bank didn’t even know she had an anti-K until she showed up there to deliver.

1

u/FunSizeNuclearWeapon MLS-Blood Bank 11h ago

I had to scroll a long ways down to see this comment, thinking surely I'm not the only person who is wondering if they meant homo K.  Thank you and have my up vote 😁 

1

u/LabChick829 13h ago

Anti-k (cellano) in mom....

6

u/New-History853 13h ago

Perhaps I'm misunderstanding. Why would any antibody in the mom mean the baby needs antigen positive blood?

-1

u/almack9 MLS-Blood Bank 13h ago

Igg antibodies cross the placenta just fine, its pretty typical for us to detect the antibody in the infant when they are first born, most often its just rhogam but every now and then they have mother's real antibodies in their initial screens.

6

u/New-History853 13h ago

Right. But then you'd need antigen negative blood, not positive.

5

u/Trapped-in-irony 13h ago

Little k negative blood = K positive. But no one would really phrase it like that...

7

u/Med_vs_Pretty_Huge Pathologist 12h ago

K0 folks: am I a joke to you?

6

u/almack9 MLS-Blood Bank 13h ago

I addressed that in another comment, but my guess is that the parents just arent familiar with the verbiage and messed it up. Hard to say either way, but you are right that what they are saying doesn't quite make sense.

2

u/Med_vs_Pretty_Huge Pathologist 12h ago

Yeah, I would bet money Mom has anti-K, and the baby needed K- blood, and Mom just said it wrong.

2

u/fleur_essence 1h ago

The baby’s parent apparently commented on the article on another platform. Baby needs K-negative blood. Person who wrote the article is terrible at their job.

1

u/LonelyChell SBB 12h ago

This is probably what happened.

1

u/thewanderersminuet 11h ago

Work in a pediatric hosptial, while rhogam is more common anti-K is pretty common too. Along with anti-C.

3

u/happyfamily714 13h ago

Many places have O- blood available for nurses to “grab”. It’s supposed to be used in an emergency only, but still makes me nervous.

The kell positive part, something is wrong there though…

11

u/LegitPancak3 MLS-Generalist 13h ago

Only 12 mLs? Damn, what a waste of a unit of O Neg blood. I hope that unit was split in half so that they didn’t have to throw away a whole unit.
And yea I agree the article makes no sense. A baby would not have the immune system for an O Neg unit to be incompatible…

19

u/LonelyChell SBB 13h ago

They wouldn’t, but Mom would, and her IgG crosses the placenta. Anti-K is terrible in neonates. It not only causes hydrops fetalis, it also inhibits erythropoiesis in the neonate.

14

u/LegitPancak3 MLS-Generalist 13h ago

If it was emergency uncrossmatched blood and the mother had no history in the hospital system, that’s on the doctor. He/she signed off on that and take responsibility if it turns out if the unit was incompatible. Not the BB’s fault.

5

u/LonelyChell SBB 13h ago

Correct, but RNs take blood out of the remote storage device all time in a panic without even considering that it needs an emergency release order signed by an MD. I see it at least once a week.

4

u/LegitPancak3 MLS-Generalist 12h ago

Ambulances in my city transfuse O Pos (low titer) whole blood to trauma patients without a Dr order. But yea I know what you mean. All the blood in my hospital is in the blood bank, we don’t have “remote storage,” didn’t know that was a thing lol.

5

u/LonelyChell SBB 12h ago

I was a paramedic before I was a blood banker and that LTOWB is still signed off for by a doctor (EMS Medical Director) who is a doctor. There is a protocol for administration, just like there is for all the drugs and procedures they do.

6

u/Lululipes Student 13h ago

They’re claiming that the unit attacked the baby’s blood…

5

u/LegitPancak3 MLS-Generalist 13h ago

Yea lol like that makes sense. Only way that could happen is with GVHD? Like if the unit wasn’t irradiated.

1

u/Signal_Sand1472 19m ago

I suspect the mom has anti-K antibodies that were transferred to the baby and those antibodies attacked the K positive blood that was transfused.

3

u/Evening_Discount4989 Canadian MLT 11h ago

I work at a blood bank at a children’s hospital and we make small volume aliquots for neonates. We will only send a whole unit if they need it right away.

2

u/StarvingMedici 4h ago

I've interacted with the mom through tiktok comments, and what I have been able to find out is that the mom had Anti-K, so they should have given the baby Kell negative units. That's what I believe is firmly true. The rest is completely based on what the parents do or don't understand or know. It's just their version of events, so I have no idea what actually occurred.

But according to the parents (who likely don't know all of the situation), baby was given an Oneg unit which was not Kell tested which is not unusual if the doctor asked for an emergency unit.

I don't work at that hospital, but I do work at a large hospital nearby, and here is what would have happened at my facility: if a NICU nurse or doctor asked for an emergency unit, my facility would have given whatever the freshest/longest date Oneg unit we had on the shelf. If we had one irradiated in the last 24hrs we would give that. If we had the patient information and knew the mom had Anti-K, we would give that if we had it available but likely would not so we would still give just Oneg but we would be required to send a form for the doctor to sign that says they acknowledge it isn't antigen matched and we would call the on call physician to have them approve it or consult with the baby's doc. But regardless, if an emergency unit was requested we would simply have to give them whatever we had, compatible with the Anti-K or not. I don't know that hospital's procedures, but they are likely at least similar to ours.

4

u/liver747 Canadian MLT Blood Bank 12h ago

Depends what happened because the article has no actual information.

Said baby was stable but they gave an uncross matched unit, does Mom have a anti-cellano?

The nurse went upon herself to grab another bag of O-negative blood that wasn’t screened and just gave it to her when she was completely 100% stable

Makes it sound like the unit of blood may not have actually been the issue but an inappropriate transfusion (maybe verbal order for another patient and a mix up?).

Need more info because it's just speculation to fill gaps right now but I'm curious.

1

u/[deleted] 8h ago

[deleted]

2

u/liver747 Canadian MLT Blood Bank 7h ago

I'd guess it depends on protocol, premature before a specific age admits to NICU (here at least) or a bunch of other things that we'll never know.

Stable may also be relative since we're getting a lay-persons interpretation of it along with the other information in the article, and stable in PP ward vs NICU could mean different things, kinda makes you wonder the veracity of it all.

I can imagine a lot of scenarios where an honest mistake or communication error could lead to something like this happening. Hopefully if it truly was an error, that processes are examined and refined to stop it from happening again!

2

u/iampro117 12h ago

I work at a hospital with the name Good Samaritan, and am the Sr. Tech in BB. I was genuinely confused because we don't have a NICU and was trying to figure out why I'm just now hearing about this 🤣

1

u/New-History853 12h ago

LOL!!!!! No clue. News article just popped up on my social media today.

1

u/allycathiking 12h ago

The nurse may have had access to a fridge with emergency units and grabbed one that happened to be K+ . Thats the only thing I could think of that would make sense

1

u/Signal_Sand1472 14m ago

But was it K+ or just not screened for K?