Transfusion Medicine Quality in Laboratory Diagnosis
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Series Editor Series Editor Michael Laposata Diagnostic Standards of Care Michael Laposata Diagnostic Standards of Care Diagnostic StandardsDiagnostic of Care Transfusion Medicine Quality in Laboratory Diagnosis Quentin G. Eichbaum, MD, PhD, MPH, MFA, FCAP, Assistant Dean for Program Development, Associate Professor of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine Garrett S. Booth, MD, MS, Assistant Professor of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine Transfusion Medicine Transfusion Pampee P. Young, MD, PhD, Associate Professor of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine Transfusion The Diagnostic Standards of Care Series presents common errors associated with diagnoses in clinical pathology, using case examples to illustrate effective analysis based on current evidence and standards. In addition to being a practical diagnostic guide, each volume demonstrates the use of quality assurance and the role of the pathologist in ensuring Medicine quality and patient safety. Quality in Laboratory Diagnosis Transfusion Medicine addresses common issues and errors seen in the blood transfusion process. The goal is to alert general practitioners and trainees to the latest scientific advances and spiraling regulations in Eichbaum • blood transfusion as well as introduce them to the most common types of transfusion errors encountered in clinical settings. Transfusion Medicine Features n Descriptions of potential errors in regulatory compliance, operational processes, and patient safety Booth • Young n Descriptions of potential errors in clinical decision making in blood transfusion, including when to premedicate patients, warfarin reversal, Quentin G. Eichbaum and the diagnostic intricacies in TRALI and TTP n Pocket-sized for portability Garrett S. Booth Pampee P. Young Recommended Shelving Category: Pathology 11 West 42nd Street New York, NY 10036 www.demosmedpub.com 9 781936 287963 Transfusion Medicine Quality in Laboratory Diagnosis EEichbaum_87963_PTR_FM_10-01-12_i-xvi.inddichbaum_87963_PTR_FM_10-01-12_i-xvi.indd I 111/10/121/10/12 112:192:19 PPMM Diagnostic Standards of Care MICHAEL LAPOSATA, MD, PhD Series Editor Coagulation Disorders Quality in Laboratory Diagnosis Michael Laposata, MD, PhD Clinical Microbiology Quality in Laboratory Diagnosis Charles W. Stratton, MD Laboratory Management Quality in Laboratory Diagnosis Candis A. Kinkus Forthcoming in the Series Clinical Chemistry Hematology/Immunology EEichbaum_87963_PTR_FM_10-01-12_i-xvi.inddichbaum_87963_PTR_FM_10-01-12_i-xvi.indd iiii 111/10/121/10/12 112:192:19 PPMM Diagnostic Standards of Care Series Transfusion Medicine Quality in Laboratory Diagnosis Quentin G. Eichbaum , MD, PhD, MPH, MFA, FCAP Assistant Dean for Program Development Associate Professor of Pathology, Microbiology and Immunology Director, Transfusion Medicine Fellowship Program Associate Professor of Medical Education and Administration Vanderbilt University School of Medicine Associate Director of Transfusion Medicine Vanderbilt University Medical Center Nashville, Tennessee Garrett S. Booth, MD, MS Assistant Professor of Pathology, Microbiology and Immunology Vanderbilt University School of Medicine Associate Director of Transfusion Medicine Vanderbilt University Medical Center Nashville, Tennessee Pampee P. Young, MD, PhD Associate Professor of Pathology, Microbiology and Immunology Vanderbilt University School of Medicine Director of Transfusion Medicine Vanderbilt University Medical Center Nashville, Tennessee New York EEichbaum_87963_PTR_FM_10-01-12_i-xvi.inddichbaum_87963_PTR_FM_10-01-12_i-xvi.indd iiiiii 111/10/121/10/12 112:192:19 PPMM Visit our website at www.demosmedpub.com ISBN: 978-1-936287-96-3 e-book ISBN: 978-1-617051-60-9 Acquisitions Editor: Richard Winters Compositor: S4Carlisle Publishing Services © 2013 Demos Medical Publishing, LLC. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Medicine is an ever-changing science. Research and clinical experience are continually expand- ing our knowledge, in particular our understanding of proper treatment and drug therapy. The authors, editors, and publisher have made every effort to ensure that all information in this book is in accordance with the state of knowledge at the time of production of the book. Nevertheless, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, express or implied, with respect to the contents of the publication. Every reader should examine carefully the package in- serts accompanying each drug and should carefully check whether the dosage schedules mentioned therein or the contraindications stated by the manufacturer differ from the statements made in this book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Proudly sourced and uploaded by [StormRG] Kickass Torrents | TPB | ET | h33t Library of Congress Cataloging-in-Publication Data Eichbaum, Quentin. Transfusion medicine : quality in laboratory diagnosis / Quentin Eichbaum, Garrett Booth, Pampee Young. p. ; cm. — (Diagnostic standards of care) Includes bibliographical references and index. ISBN 978-1-936287-96-3 ISBN 1-936287-96-X I. Booth, Garrett. II. Young, Pampee. III. Title. IV. Series: Diagnostic standards of care. [DNLM: 1. Blood Transfusion—adverse effects. 2. Hematologic Diseases—diagnosis. 3. Medical Errors—prevention & control. 4. Patient Safety—standards. 5. Quality Assurance, Health Care. WB 356] 615.3’90289—dc23 2012029073 Special discounts on bulk quantities of Demos Medical Publishing books are available to corporations, professional associations, pharmaceutical companies, health care organiza- tions, and other qualifying groups. For details, please contact: Special Sales Department Demos Medical Publishing , LLC 11 W. 42nd Street, 15th Floor New York, NY 10036 Phone: 800–532–8663 or 212–683–0072 Fax: 212–941–7842 E-mail: [email protected] Printed in the United States of America by Gasch Printing. 12 13 14 15 / 5 4 3 2 1 Eichbaum_87963_PTR_FM_10-01-12_i-xvi.indd iv 11/10/12 12:19 PM QE: To the transfusionists and laboratory technologists in the developing world, who strive with limited resources to improve the quality and safety of blood transfusion. GB: To the residents at Vanderbilt University Medical Center. PY: To my mentors and my students from whom I have learned much. EEichbaum_87963_PTR_FM_10-01-12_i-xvi.inddichbaum_87963_PTR_FM_10-01-12_i-xvi.indd v 111/10/121/10/12 112:192:19 PPMM EEichbaum_87963_PTR_FM_10-01-12_i-xvi.inddichbaum_87963_PTR_FM_10-01-12_i-xvi.indd vvii 111/10/121/10/12 112:192:19 PPMM Contents Series Foreword xi Preface xi ii Acknowledgments xvi 1 Product-Related Errors 1 Inappropriate Use of Fresh Frozen Plasma (FFP) to Correct Mildly Elevated Prothrombin Time (PT) 2 Inappropriate Use of Fresh Frozen Plasma (FFP) for Volume Expansion 5 Inappropriate Use of Rh Immune Globulin (RhIG) in Pregnancy 7 Rh Immune Globulin (RhIG)—Inadequate Dosing 9 Inappropriate Use of Cryoprecipitate 12 Platelet Inactivation as a Result of Cold Exposure 15 2 Errors in Procedures 19 A Positive Type and Screen Will Result in Relative Delay in the Issue of Blood 20 Error in Blood Sample Collection Resulting in Inaccurate Type and Screen 23 EEichbaum_87963_PTR_FM_10-01-12_i-xvi.inddichbaum_87963_PTR_FM_10-01-12_i-xvi.indd vviiii 111/10/121/10/12 112:192:19 PPMM viii Contents Misinterpretation of Laboratory Tests for Hemolysis 25 ABO Typing Discrepancy Due to Less Common ABO Subgroups 28 Inappropriate Use of Autologous Blood 31 Rapid Transfusion in Chronic Anemia May Result in Volume Overload 34 Cold Agglutinin Disease (CAD)—Insignifi cance of Low Antibody Titers 36 Hypocalcemic Toxicity from Therapeutic Plasma Exchange (TPE) 38 Hemolysis Following Platelet Transfusion 41 Development of Coagulopathy Secondary to Intensive Therapeutic Plasma Exchange (TPE) 44 Heparin-Flushed Lines—Inadvertent Exposure to Blood Circulation 47 3 Errors Involving Specifi c Clinical Scenarios 51 Occult Anemia—Searching for a Delayed Hemolytic Transfusion Reaction 53 Identifi cation and Management of Clinically Signifi cant Alloantibodies in Pregnancy 56 Liberal Versus Restrictive Transfusion Strategies 59 Non-Evidence-Based Practices in Prophylactic Platelet Transfusions for Minor Procedures 61 Eichbaum_87963_PTR_FM_10-01-12_i-xvi.indd viii 11/10/12 12:19 PM Contents ix Molecular Differences in the RhD Protein and the Need for Rh Immune Globulin 63 Recognition of Immune-Mediated Hemolysis in a Pediatric Patient 66 Inappropriate Platelet Transfusion for Patients on Aspirin 70 Unexpected Posttransfusion Purpura (PTP) 73 Phenotype Matching to Mitigate Alloimmunization in Sickle Cell Disease 76 Refusing Blood Transfusion, When Patient and Physician Beliefs Fail to Align 79 Crypt Antigen Activation, Adverse Consequences 82 Failure to Recognize Specifi c Risk Factors That Are Associated with Adverse Reactions in Blood Donors 85 Misinterpretation of the Direct Antiglobulin Test (DAT) 87 Warfarin Reversal—Inappropriate Use of Fresh Frozen Plasma 90 Anti-Kell Alloantibodies—Missed Diagnosis of Hemolytic Disease of the Fetus and Newborn