A doctor of Pharmacy who works in a Corporate Quality department in a Patient Safety division reports that according to a recent survey, Rh Immune Globulin (RHIG) storage and distribution are controlled/dispensed either by the laboratory or the pharmacy, according to institution preference. The PharmD wonders if colleagues of the e-network forum would share their recommendations as to the most appropriate location for RHIG storage (and why) and their local procedure of storage and distribution of RHIG. She realizes that it does not matter where the RHIG is stored, so long as it is provided for patient care according to the recommendations of the most current Physicians' Desk Reference (including dispensing of the intravenous preparation of RHIG (WinRho), the ACOG , the AABB , and 'Practice guidelines for prenatal and perinatal immunohematology, revisited', from Transfusion, Vol. 41, No. 11, 1445-1452, November 2001.

In response to the above question, the following replies have been submitted. 

1. A blood banker in Texas wrote that they order RHIG directly from the manufacturer. Then they store and issue the RHIG from the blood bank. They do this for the following reasons:

• The blood bank performs Rh typing and has access to the woman's historical blood type (if she has been typed by the lab in the past) 
• The blood bank performs the cord blood testing after delivery 
• The blood bank does the Rosette or Kleihauer Tests to determine how many vials of RHIG are necessary after delivery (to assure the correct dose is administered)
• The blood bank can do the necessary typing of a patient seen in the ER with a spontaneous abortion.

ADDENDA June 13, 2002

2. A blood banker in Northern California reports that when their maternity department was closed, her community hospital transferred the storage and distribution of RHIG from the blood bank to the pharmacy department. Presently, RHIG is now dispensed mainly in the Emergency Department for miscarriages and the Surgery Department for missed abortions. There is a computer prompt to check that the patient is Rh-negative before accessing the product in the pharmacy.

ADDENDA June 14, 2002

3. A blood bank physician who oversees transfusion medicine services in a hospital near the US Capitol wrote that with regard to storage (and, most importantly, distribution) of RhIG, this blood product belongs in the hospital blood bank. The responding physician adds that the decision process starts with IV RhIG (for ITP) which, because of cost and potential toxicity in the wrong patient, requires the same verification of blood type and oversight of the clinical indication as a blood component. The indications and contraindications with regard to blood type, splenectomy, pregnancy, hematocrit and diagnosis are too clinically and serologically complex to be dispensed without the same oversight that is required for dispensing other blood type-specific blood products. He also is of the opinion that once it becomes clear that IV RhIG must be issued via the blood bank's process for oversight of blood utilization, it follows that IM RhIG should accompany it for the same, although less urgent, reasons. In his hospital, most OB patients' initial blood type and screen is required by their insurance program to be sent to an external so-called reference laboratory. Nevertheless, his hospital blood bank does not dispense IM RhIG to a woman with a prescription or physician's order unless they have performed their own blood type and screen, even if they have to perform it without reimbursement. Recently (in June 2002), they detected a Rh(D) typing error by one of these "reference" laboratories when an Rh(D)-positive women presented in her 28th week of pregnancy with a prescription for prophylactic IM RhIG.. Pharmacies dispensing IM RhIG perpetuate these errors and create confusion about their correct blood type when the patients deliver. When a blood bank distributes IM RhIG according to its own blood typing result, it establishes blood type records in advance of the delivery and where the information is needed. At the time of the 28-week immunoprphylaxis, an RhIG-dispensing blood bank can correct any errors by outside laboratories and establish accurate records for the delivery.

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator