A colleague in the Eastern USA reports that a hospital in the same community as her institution recently had an inspection by the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), which resulted in the other hospital being ‘cited’ because their transfusion reaction workup protocol did not require the laboratory to perform ABO/Rh testing on the post-transfusion patient specimen and repeat ABO/Rh typing of the RBC unit in question. The reason that the inquiring colleague is concerned about this citation (even though it was at another facility) is that her laboratory follows the exact same protocol as the faciltiy that reportedly was cited. The procedure they use is as follows:

If there is no clerical error discovered, no evidence of hemolysis and the DAT is negative, then no further work-up is necessary.

The JCAHO inspector allegedly said that new regulations now required hospital transfusion services to perform ABO/Rh testing on the post-transfusion patient specimen and repeat ABO/Rh typing on the RBC unit in question. The inquiring colleague's hospital is currently CAP-accredited, and they cannot find this 'new' JCAHO requirement anywhere. She wants to know if such a JCAHO requirement truly exists, and if so, where can the documentation be found?

Editor's comment: The above question was forwarded to an individual who is extremely knowledgeable of the JCAHO inspection process. He suggests that the ‘cited’ institution check with the office of Standards at JCAHO. According to a source there, such a blanket requirement does not exist. However, one might assume, based on AABB Standards and good practice, that an institution should perform ABO/Rh testing on a post-reaction patient blood sample and on the implicated unit, if a hemolytic reaction is suspected. Thus, if the hospital's policy is not to do retyping for ANY transfusion reaction, even if hemolytic, then that would be problematic, and subject to ‘citation’ by JCAHO. Assuming that the hospital does not have such a policy, then they should give a formal call to the JCAHO Standards office for an official review of the matter.

1. Check for clerical errors.
2. Collect post-transfusion urine and blood specimens. Check all specimens for hemolysis.
3. Perform Direct Antiglobulin (DAT) testing of both the pre- and post-transfusion sample.

The following comments have been received.

ADDENDA Nov. 12, 2004

1. A colleague in Pennsylvania reports that she has not seen a new JCAHO requirement that requires the ABO group must be performed on a post-transfusion patient sample, as part of a transfusion reaction, but she does point out that the 22nd edition of the AABB Standards (effective November 1, 2003) added the following statement to Standard 7.4.3 Immediate Transfusion Recipient Complications, item 7.4.3.1.4: “A repeat ABO group determination shall be performed on the posttransfusion sample.” In her opinion, the inquiring colleague appears to have failed to identify this additional requirement during their change control process for implementation of the revised standards. Perhaps this oversight occurred as this new item was not specifically identified in the preface list which highlighted key revisions.

2. A colleague in Sacramento reports that he does not know about a new JCAHO requirement, but believes that it is certainly a good idea to detemine the ABO group of a post-transfusion reaction patient sample. He has taught this concept for years since ABO errors/mishaps are potentially the most serious. In his opinion, repeat ABO testing of the patient and a sample from inside the unit shoud be done as part of the immediate evaluation. If the ABO of the patient and unit are correct and compatible, along with the other immediate negative findings, it is very unlikely that a hemolytic transfusion reaction has occurred, at least one due to a major ABO incompatibility.

ADDENDA Nov. 16, 2004

3. A colleague in Wisconsin reports that at his institution they test the post-reaction patient sample for ABO/Rh as part of the "1st Tier" phase of every transfusion reaction evaluation done by the laboratory. This phase includes a clerical check of all documentation, labels, etc, and testing of the post-reaction patient sample for ABO/Rh, direct antiglobulin test (DAT) and hemolysis. Their clerical check includes a computer records review to confirm that the implicated unit's blood type was correctly entered into their computer, that the unit had its blood type verified by the lab before making it available for transfusion, and that the unit's blood type was compatible for the patient. If there are any "positive" results in this first tier of the transfusion reaction evaluation (eg, positive DAT, hemolysis, urine bloody, etc) they would then do many other tests, including repeat ABO typing of all units implicated, as well as pre and post antibody screening, antigen typing (if unexpected antibody is present), etc.

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