Case Report
Reactive donor notification: First error reported Urvershi Kotwal, Veena Doda, Satyam Arora, Meena Joshi
Blood Bank, Dr. Ram Manohar Lohia Hospital, New Delhi, India
Abstract: Donor notification and post-donation counseling is an essential role of blood bank. If a donor is reactive for any marker, the blood bank counselor, informs the donor and advices him/her to report to the blood bank for further counseling and management. The counselor at our blood bank informed a young female voluntary donor to be reactive for HIV both with ELISA as well as NAT. When the donor reported to blood bank, the repeat testing was negative and no history of high risk behavior could be elicited. The hospital information system (HIS) records were checked again immediately for clarification and showed consistency with her demographic profile. But when her manual records and donor questionnaire were retrieved, showed information displayed in the HIS system was wrongly interpreted by the counselor. In this era of information technology being highly advanced, the role of manual record keeping is still the gold standard. Key words: Donor notification, hospital information system, reactive donor
Access this article online Website: www.ajts.org DOI: 10.4103/0973-6247.137456
Quick Response Code:
Correspondence to: Dr. Veena Doda, Department of Blood Bank, Dr. Ram Manohar Lohia Hospital, New Delhi, India. E-mail: veenadoda@ gmail.com
Background
Case Report
Notification of a blood donor about the abnormal test results is a very sensitive and crucial aspect of post-donation counseling as it has its psychological and social impact. Each donor reacts in a different manner, some people faint, get angry, deny vehemently, start weeping, very calm apparently followed by nervous breakdown and various other emotional disturbances.
As a routine, all the TTI-reactive donors, irrespective of either ELISA or NAT reactivity, are notified and called for post-donation counseling. The Blood Bank counselor informed that one of the donor samples is found to be reactive for HIV both with ELISA as well as NAT. As per the counselor, HIS for blood bank showed the donor demographic profile to be a 19-year-old female, first-time voluntary donor in an outdoor camp from Delhi. According to the protocol, the donor was communicated telephonically and asked to report to blood bank for further counseling. A reminder call was given after 2 days. She reported to blood bank, after a week of the first call along with her father. Seeing the sensitivity of the issue (young female donor), counseling was done by the doctor on duty to elicit history of any high risk behavior and correlate with the results. One-to-one counseling was done by the female counselor also. No highrisk behavior was elicited. On discussion about the disclosure of abnormal test results to her father, the consent was given by her. A sample was also taken for repeat testing and she was also referred to ICTC for further management.
Blood bank at our hospital provides blood for the patients after mandatory TTI testing by ELISA[1] as well as Nucleic Acid Testing (NAT) for HIV, HBV and HCV. Testing is done on pilot tubes sample as well as samples from the bag before labeling it as seroreactive. The aim of NAT testing is to ensure an added layer of blood safety for the recipients. [2] Donor notification and postdonation counseling is an essential aspect of blood bank these days for reactive donors.[3] It entails provision of information on serological status, assess the impact of test results on donor and finally referral for medical care. In case of a donor reactive for any marker, the blood bank counselor informs the donor either telephonically or by post about detection of abnormal test results with an advice to report to the blood bank for one to one counseling, repeat sampling as well as for referral to the respective department of the hospital for further management. As a protocol, three phone calls and one letter are sent by post to inform the donor about any abnormal result before their noncompliance is termed as non-responder.
Asian Journal of Transfusion Science - Vol 8, Issue 2, July - December 2014
The repeat sample was found to be non-reactive on rapid testing on the same day. The HIS records on the computer were checked again immediately for clarification, and showed consistency with her demographic profile. On the contrary, when the manual records and donor questionnaire were retrieved, they showed a different name and demographic profile on the form as well as on the manual record in comparison to the one in the 135
Kotwal, et al.: Error reported in reactive donor notification
information displayed by the HIS system. The error was identified and traced as the information displayed in the HIS system was wrongly interpreted by the counselor. The tab/window of the total registration of the donors which bears the serial number of the total donor recruitment (fit/unfit) instead of the tab/window for the blood donor register which bears the donor number was scrolled by her leading to this grave error. The donor was immediately communicated about the catastrophic error due to negligence of the blood bank staff. It was a sign of relief for the donor and her family. This gave us a hard lesson to testify and confirm the records both manually and HIS for any such further course of action. Moreover, repeat test results on the fresh donor sample and sample from the bag showed non-reactive results by ELISA as well as NAT the following day. The ICTC also confirmed the sample to be non-reactive the next day. The confirmed reactive donor was then communicated for counseling and further management.
notification. Switching over from manual record keeping to electronic data should be transitional, for all the staff to learn the nitty gritties of the software to avoid any such grave consequences. Time-to-time validation of the software should also be undertaken. Moreover, it is imminent that the donor questionnaire should always be retrieved and reviewed before donor notification.
References 1.
2.
3.
Discussion In spite of the advancements in the field of information technology, role of manual record keeping is still the gold standard. As in our case, there was an inadvertent error in opening the correct window of HIS. Total registered donors instead of blood donor register were scrolled by the counselor for donor
136
Nacoonline.org. Standards for Blood Bank and Blood Transfusion Services. Available from: h p://www.nacoonline. org/NACO/Quick_Links/Publication/Blood_Safety__Lab_Services/ Operational__Technical_guidelines_and_policies/standards_for_ blood_bank/ [Last accessed on 2007 Aug 29]. Kleinman SH, Lelie N, Busch MP. Infectivity of human immunodeficiency virus-1, hepatitis C virus, and hepatitis B virus and risk of transmission by transfusion. Transfusion 2009;49:2454-89. Nacoonline.org. An Action Plan for Blood Safety. Available from: http://www.nacoonline.org/NACO/Quick_Links/Publication/ Blood_Safety__Lab_Services/Others/An_Action_Plan_for_Blood_ Safety/ [Last accessed on 2007 Aug 29].
Cite this article as: Kotwal U, Doda V, Arora S, Joshi M. Reactive donor notification: First error reported. Asian J Transfus Sci 2014;8:135-6. Source of Support: Nil , Conflicting Interest: None declared.
Asian Journal of Transfusion Science - Vol 8, Issue 2, July - December 2014
Copyright of Asian Journal of Transfusion Science is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Reactive donor notification: First error reported Urvershi Kotwal, Veena Doda, Satyam Arora, Meena Joshi
Blood Bank, Dr. Ram Manohar Lohia Hospital, New Delhi, India
Abstract: Donor notification and post-donation counseling is an essential role of blood bank. If a donor is reactive for any marker, the blood bank counselor, informs the donor and advices him/her to report to the blood bank for further counseling and management. The counselor at our blood bank informed a young female voluntary donor to be reactive for HIV both with ELISA as well as NAT. When the donor reported to blood bank, the repeat testing was negative and no history of high risk behavior could be elicited. The hospital information system (HIS) records were checked again immediately for clarification and showed consistency with her demographic profile. But when her manual records and donor questionnaire were retrieved, showed information displayed in the HIS system was wrongly interpreted by the counselor. In this era of information technology being highly advanced, the role of manual record keeping is still the gold standard. Key words: Donor notification, hospital information system, reactive donor
Access this article online Website: www.ajts.org DOI: 10.4103/0973-6247.137456
Quick Response Code:
Correspondence to: Dr. Veena Doda, Department of Blood Bank, Dr. Ram Manohar Lohia Hospital, New Delhi, India. E-mail: veenadoda@ gmail.com
Background
Case Report
Notification of a blood donor about the abnormal test results is a very sensitive and crucial aspect of post-donation counseling as it has its psychological and social impact. Each donor reacts in a different manner, some people faint, get angry, deny vehemently, start weeping, very calm apparently followed by nervous breakdown and various other emotional disturbances.
As a routine, all the TTI-reactive donors, irrespective of either ELISA or NAT reactivity, are notified and called for post-donation counseling. The Blood Bank counselor informed that one of the donor samples is found to be reactive for HIV both with ELISA as well as NAT. As per the counselor, HIS for blood bank showed the donor demographic profile to be a 19-year-old female, first-time voluntary donor in an outdoor camp from Delhi. According to the protocol, the donor was communicated telephonically and asked to report to blood bank for further counseling. A reminder call was given after 2 days. She reported to blood bank, after a week of the first call along with her father. Seeing the sensitivity of the issue (young female donor), counseling was done by the doctor on duty to elicit history of any high risk behavior and correlate with the results. One-to-one counseling was done by the female counselor also. No highrisk behavior was elicited. On discussion about the disclosure of abnormal test results to her father, the consent was given by her. A sample was also taken for repeat testing and she was also referred to ICTC for further management.
Blood bank at our hospital provides blood for the patients after mandatory TTI testing by ELISA[1] as well as Nucleic Acid Testing (NAT) for HIV, HBV and HCV. Testing is done on pilot tubes sample as well as samples from the bag before labeling it as seroreactive. The aim of NAT testing is to ensure an added layer of blood safety for the recipients. [2] Donor notification and postdonation counseling is an essential aspect of blood bank these days for reactive donors.[3] It entails provision of information on serological status, assess the impact of test results on donor and finally referral for medical care. In case of a donor reactive for any marker, the blood bank counselor informs the donor either telephonically or by post about detection of abnormal test results with an advice to report to the blood bank for one to one counseling, repeat sampling as well as for referral to the respective department of the hospital for further management. As a protocol, three phone calls and one letter are sent by post to inform the donor about any abnormal result before their noncompliance is termed as non-responder.
Asian Journal of Transfusion Science - Vol 8, Issue 2, July - December 2014
The repeat sample was found to be non-reactive on rapid testing on the same day. The HIS records on the computer were checked again immediately for clarification, and showed consistency with her demographic profile. On the contrary, when the manual records and donor questionnaire were retrieved, they showed a different name and demographic profile on the form as well as on the manual record in comparison to the one in the 135
Kotwal, et al.: Error reported in reactive donor notification
information displayed by the HIS system. The error was identified and traced as the information displayed in the HIS system was wrongly interpreted by the counselor. The tab/window of the total registration of the donors which bears the serial number of the total donor recruitment (fit/unfit) instead of the tab/window for the blood donor register which bears the donor number was scrolled by her leading to this grave error. The donor was immediately communicated about the catastrophic error due to negligence of the blood bank staff. It was a sign of relief for the donor and her family. This gave us a hard lesson to testify and confirm the records both manually and HIS for any such further course of action. Moreover, repeat test results on the fresh donor sample and sample from the bag showed non-reactive results by ELISA as well as NAT the following day. The ICTC also confirmed the sample to be non-reactive the next day. The confirmed reactive donor was then communicated for counseling and further management.
notification. Switching over from manual record keeping to electronic data should be transitional, for all the staff to learn the nitty gritties of the software to avoid any such grave consequences. Time-to-time validation of the software should also be undertaken. Moreover, it is imminent that the donor questionnaire should always be retrieved and reviewed before donor notification.
References 1.
2.
3.
Discussion In spite of the advancements in the field of information technology, role of manual record keeping is still the gold standard. As in our case, there was an inadvertent error in opening the correct window of HIS. Total registered donors instead of blood donor register were scrolled by the counselor for donor
136
Nacoonline.org. Standards for Blood Bank and Blood Transfusion Services. Available from: h p://www.nacoonline. org/NACO/Quick_Links/Publication/Blood_Safety__Lab_Services/ Operational__Technical_guidelines_and_policies/standards_for_ blood_bank/ [Last accessed on 2007 Aug 29]. Kleinman SH, Lelie N, Busch MP. Infectivity of human immunodeficiency virus-1, hepatitis C virus, and hepatitis B virus and risk of transmission by transfusion. Transfusion 2009;49:2454-89. Nacoonline.org. An Action Plan for Blood Safety. Available from: http://www.nacoonline.org/NACO/Quick_Links/Publication/ Blood_Safety__Lab_Services/Others/An_Action_Plan_for_Blood_ Safety/ [Last accessed on 2007 Aug 29].
Cite this article as: Kotwal U, Doda V, Arora S, Joshi M. Reactive donor notification: First error reported. Asian J Transfus Sci 2014;8:135-6. Source of Support: Nil , Conflicting Interest: None declared.
Asian Journal of Transfusion Science - Vol 8, Issue 2, July - December 2014
Copyright of Asian Journal of Transfusion Science is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
