Category: Administration

Administrative documents, not necessarily technical or medical

Opinion: Outsider Access to Blood Bank Software

drzeyd

I designed my blood bank software Medinfo for use by my staff at all levels and positions to adhere to and facilitate compliance to the workflow processes.  Blood bank staff were restricted to access only those functions needed for their job duties.

Blood Donation records could not be viewed by outside staff for confidentiality reasons.  Blood donor records were not linked to patient records at all.

We did not allow access for Medinfo to non-Transfusion Medicine staff since the screens were designed to maximize efficiency of the work processes, not the viewing by outsiders of results.  Outsider access was made through the hospital information system HIS.

The separate hospital information system HIS interfaced to Medinfo for the following functions:

  • Ordering blood components
  • Ordering a limited number of tests from which algorithms would be generated on the blood bank side for further testing
  • Querying the status of the test or component orders (e.g. ordered, collected, in blood bank being processed, completed)
  • Viewing of completed tests and component requests

Even within the HIS ordering capabilities, there were additional restrictions:

  • Blood components:  outside doctors could order base blood components could be ordered, but special processing such as washing or irradiation followed internal blood bank rules.  Outside physicians could state their preferences in an order comment, but blood bank rules applied.  Any disagreements had to be discussed with the transfusion medicine physician.
  • Testing:  Only base tests such as ABO/D typing, antibody screen, direct antiglobulin test, transfusion reaction workup, and cord blood testing could be directly ordered by outside physicians, but further testing depended on the results of these tests as allowed by internal blood bank algorithms.  An outside physician could not directly order other tests but had to discuss his concerns with the transfusion medicine physician.

Results viewing in the HIS were subject to additional conditions as well:

Only certain results, not all results were viewable directed in the patient’s chart since showing all results may be confusing to the outside physicians and nurses.  The selected results were sent back into the HIS for viewing.  All these non-viewable results were retrievable for blood bank staff in Medinfo.

Another option, one I did not use at either HMC Doha or NGHA in Saudi Arabia, was to order tests and components by physicians directly into Medinfo.  Likewise, they could view test results directly in the system.  Special screens could be constructed to offer ordering and results retrieval.

Use of Expired Reagents

drzeyd

This is a sample document for use of expired reagents I wrote for HMC Qatar.

Principle:

Due to logistics issues including the long distance between suppliers in Europe and North America and Qatar and the importation/customs clearance of critical materials, Transfusion Medicine has developed a contingency variance policy to minimize disruption of the essential transfusion medicine testing and component preparation.  Approval for use of outdated reagents in special circumstances is not meant to be an excuse for untimely monitoring and improper ordering of supplies.

Definition:

Rare Reagent:  Any reagent that is either used uncommonly or is in short supply and difficult to obtain in a timely matter.

Policy:

  1. Maintain a minimum six (6) months’ supply of each reagent when feasible.
    1. This cannot be done for short-outdate reagents such as reagent red cells for panels and antibody screens.
  2. If an in-date reagent is not available for use, then an outdated reagent may be considered for use if:
    1. It passes an in-run quality control including negative and positive controls as applicable specific for the test in question.
    1. Supervisor reviews the results and approves their use:
      1. Results using such outdated reagents may only be used if they pass the validation rules in that procedure.
    1. The Division Head, Transfusion Medicine, or designate reviews the supervisor’s recommendations and approves their use.
  3. All such variances must be documented as follows:
    1. Variance document form
    1. In the comments for results within the Medinfo Hematos IIG software.

References:

Sections 1.3.2 and 7.0, Standards for Blood Banks and Transfusion Services, Current Edition, AABB, Bethesda, MD, USA

Rules in Medinfo Hematos IIG Blood Bank Software

drzeyd

Medinfo Hematos IIG has an underlying framework of functionality.  It is flexible since it acts upon rules based on parameters (e.g. sex, age, diagnosis, test results, etc.)  You can change the processes in the system by changing the parameters without upsetting the underlying structure of the software.  This means you can make changes very simply and quickly without having to “hard-code.”

Rules are based on parameters which are entered into the system by the user or the results of previous action.  I am listing here some examples of parameters used to define processes in my Medinfo installations:

  • Demographics (e.g. age, sex, nationality, address)
  • Diagnosis
  • Ordering Physician
  • Project (e.g. research project)
  • Location (e.g. hospital ward or clinic)
  • Procedure (e.g. apheresis, surgical)
  • Test results (ABO typing, DAT, marker testing, control values)

Based on these parameters, the system may require:

  • Specific selection of component, derivative
  • Special processing of component
  • Selection of specific test methodology
  • Discard of blood component
  • Invalidation of test rests (e.g. positive D control)

Examples:

  • Restrict use of CCP if SARS-CoV-2 antibody titer is low
  • Discard component if HBsAb quantitation below a threshold (e.g. 100 IU/liter)
  • Hematology ward patients only to receive irradiated blood components
  • Patients in research project to have special testing always done
  • Patients with unexplained hemolysis to have special DAT performed (IgG, IgA, IgM, C3c, C3d)
  • If anti-Kell present, only use K-negative blood—if Kell positive or Kell untested, block allocation
  • If female donor, whole blood only to be processed for RBCs
  • Reflex testing (if HBcAb reactive, then HBsAb must be performed)

Overriding rules:

One can also define if the rules can be overridden by someone with appropriate credentials:

  • Use antigen-incompatible RBCs (e.g. C-positive in a patient with anti-C)
  • Use of non-irradiated RBCs if irradiator is broken

On the other hand, rules can be specified to prohibit overriding:

  • Use of group O RBCs in a patient with anti-H

Validation of Reporting Formats

drzeyd

The attached PDF illustrates a sample validation of reporting formats for transfusion service testing.  The validation criteria are explicitly stated.  The evidence, in forms of screen shots, is attached to the PDF.  The data is reviewed and then accepted by me as the Division Head, Laboratory Information Systems.

Please note in this sample, no actual patient data was used.  All testing was done in a non-production environment.

Here are the embedded screenshots:

Opinion: Software Permissions for Blood Bank Staff

drzeyd

In my career, I have worked with many different hospital and laboratory computer systems.  One of my greatest frustrations has been providing software permissions to staff at all levels, from clerical, nursing, technical, and medical—inside and outside the blood bank.

The software permissions that I am specifically referring to are those with the blood bank software.  These I directly controlled as Division Head of Transfusion Medicine and Laboratory Information Systems.  I am not talking about virtual private networks or Citrix or cloud-based software controlled by the hospital IT department.

Here are some examples of inappropriate permissions:

  • All staff share the same access, regardless of position or department
  • Technical staff, including non-blood bank staff have global access to all functions
  • Non-blood bank staff can modify test results or comments

The golden rule is to only give access that is needed for each staff’s job designation.  Staff must sign an agreement not to access the system except for work and not release anything to non-designated personnel.

I recommend separating privileges by:

  • Blood bank vs non-blood bank staff
  • Blood bank section and location
  • Technical privileges by rank:  trainee vs base technologist vs senior technologist vs supervisor vs technical director
  • Medical privileges by rank:  residents/fellows, junior medical staff, senior staff, head of sections/directors

Permissions within a test category may include test ordering, result entry, verification/authorization, and/or purging.  In the donor center, it may include registration, donor qualification, collection, donor marker testing, donor immunohematology, component processing, component modification, and/or inter-depot transfer of components.  Management tools included in the software may also be restricted to high-level staff.

In this time of COVID and staffing shortages, we may be training new staff to work in the blood bank.  During their training, these trainees can be competency assessed and be given access to limited functions.  In Medinfo Hematos IIG, you can give staff custom permissions test-by-test so for example, if they are deemed competent for ABO/D typing, you could restrict their access to only those tests as an interim measure.

Having customized access for each employee can be nightmare for the systems administrators so this granular special access must be kept to a minimum.  However, it is good to know that you do have this capability if needed.

Teaching Document: Variances in Transfusion Medicine

drzeyd

Principle:

In accordance with AABB Standards, all actions contrary to the standard operating procedures and policies of Transfusion Medicine must be specifically approved by the Head, Transfusion Medicine or designate.

Documentation of variances must be organized in a system for ready retrieval for analysis.  They should not be entered into a system that is cumbersome to find the entered variances.

Examples include but are not limited to:  Rh(D)-incompatible transfusions, least-incompatible crossmatch, extension of expired rare reagents, etc.

If the same variance is occurring frequently, it should be determined if modifications in the underlying documentation (policies, processes, procedures) should be made.

Policy:

  1. Whenever there is need for a variance in the policies and procedures in Transfusion Medicine, the Division Head, Transfusion Medicine or designate must be informed.
  2. The Division Head or Designate will review and accept/reject the request.
  3. If accepted, the variance must be documented in writing by any of the following:
    1. A paper form (pre-blood bank computer system implementation) that can ultimately be scanned or an electronic version stored in Transfusion Medicine.
    2. A comment in an appropriate field in the Medinfo computer system
  4. All verbal authorizations for a variance (e.g. telephone call to Transfusion Medicine physician at night) must be recorded on a form and submitted to the responsible TM physician for review and signature.
  5. All variance documentation must be readily retrievable for analysis.
  6. All variances must be collated and assessed as part of the monthly quality review.

References:

  1. Technical Manual, Current Edition, AABB, Bethesda, MD, USA
  2. Standards for Blood Banks and Transfusion Services, Current Edition, AABB, Bethesda, MD, USA

Issues with Labels

drzeyd

You can have the most sophisticated blood bank software, but if you can’t read the labels or if they fall off, you have a disaster.  These are my thoughts from implementing our blood bank computer system back in 2013.

Check Digits:

Both ISBT specimen and product labels have an internal system to verify that they have been read correctly.  Within the blood bank software, this should not be a problem.  However, can your third party such as a hospital information system HIS read them?

ISBT Compatibility:

The institution’s HIS could not read the component labels.  To this date, the problem has not been fixed.  As a workaround, we sent them the ISBT label codes directly from the blood bank software.  The only complete transfusion record was in the dedicated blood bank computer system, not the HIS.  You could not rely on the bedside nursing entry at all.

The HIS did not use the ISBT database and had no values for the E codes.  Again, we had no choice but to send an abbreviated E-code descriptor to them.  We did not use their transfusion module at all, but one of our clients did.  They had to hard code the list of E codes in use with their descriptors into their HIS.

Label Adhesive

We tested candidate labels at room temperature, 1-6, minus 18, and minus 80 C.  We found that most of the labels’ adhesive were not sticking at minus 80.  For some, you could literally blow on the blood bag and the label fell off.  I imagined a scenario in which I opened a freezer and saw the blood bag labels all lying separately at the bottom.

RFID Tags:

Do you use an RFID tag integrally attached to the ISBT label OR do you stick a separate RFID tag?  If the latter, how do you ensure that you put the proper tag on the proper bag?

Readability:

Readability:  Can all your blood bank devices read your printed labels?  Do you have to adjust the printers for this?  Whose responsibility is it to do this? 

Labels printed outside the blood bank:

If you receive patient specimens from outside the blood bank, can your devices read them?  Who is responsible to adjust the printers in the wards and clinics?

Validations:

Who validated that the HIS prints the accurate complete label for the right patient?  We discovered that this was not the case with our HIS and needed correction by them.  Remember that any processes affecting Transfusion Medicine should be assessed by Transfusion Medicine.  Do not accept verbal assurances from anyone, not even your HIS.

2/2/21

Teaching Document: Validation Process

drzeyd

This is a teaching document for medical technology and transfusion fellows to explain the general structure of a validation.

Principle:

All validations must be planned.  A validation protocol must be prepared with specific criteria for acceptance.  All validations with attached evidence must approved by the Head, Transfusion Medicine.

Policy:

  1. A written validation protocol must be prepared in the advance and at least including the following:
    1. Specific parameters and number of iterations to be performed
    1. Designated staff to perform validation
    1. Documentary evidence of the testing
    1. Specific acceptability criteria
  2. The completed validation protocol must be submitted to the Division Head, Transfusion Medicine, or designee for review.
  3. Once the validation plan has been reviewed, it must be performed by the designated staff.
    1. Software validations will be performed in a specific test environment, not in the live, production system.
  4. The completed validation document, including screenshots of the software functionality if applicable, must be submitted to the Division Head, Transfusion Medicine for review.
  5. The equipment or software may only be used if the acceptability are met AND the validation is approved by the Division Head, Transfusion Medicine or designee.
  6. The completed validation protocol will be stored in the document control system.

Reference:

Standards for Blood Banks and Transfusion Services, Current Edition, Bethesda, MD, USA

Blood Component Variances

drzeyd

Principle:

AABB Standards requires that all variances are documented and investigated and corrective actions taken when necessary.  Any time a blood component is found to be defective (e.g. broken seal, leaking, discoloration, clots, etc.), mislabeled, or testing results incomplete or not documented,  the cause should be investigated by the Donor Center and reported back to the initiator of the report in writing.

Policy:

  1. All transfusion services must inspect all blood components upon receipt (e.g. for leakage, broken seals, improper temperature, clots, discoloration, gas, etc.).
  2. Labels must be compared to the consignment sheet for complete concordance.
  3. If units are found that are not listed or mislabeled, they must be reported in writing to the Donor Center and returned as-is for investigations.
    1. If the unit is leaking or broken, ensure standard/universal precautions are taking to minimize contact with the fluids.
    2. Damaged blood components must not be used.  Units with mislabelings or other discrepancies between the labels and the consignment sheets may be used when such errors are corrected and officially reported by the Donor Center.
  4. Use the standard incident (occurrence variance) report form (OVA) for each and every variance.
  5. The submitting location should keep a copy of the OVA and immediately forward the original to the Transfusion Quality Section.
  6. The Donor Center should investigate the variance and prepare a written investigative report and submit to the Division Head, Transfusion Medicine.
    1. Donor Center investigations should be completed within one calendar week.
  7. The Donor Center should forward a copy of the completed written investigation to the transfusion service which initiated the investigation.
  8. The copy of the investigation report should be attached to the OVA and kept at the local site.
  9. Transfusion Quality shall include these variances in its monthly reports.

References:

Standards for Blood Banks and Transfusion Services, Current Edition, AABB, Bethesda, Maryland, USA