Temperature Excursion in the Blood Bank Refrigerator
On Monday morning, the blood bank refrigerator alarm log shows that the temperature was 8.2°C from 02:10 to 02:55. The on-call technologist documented the alarm but did not move the units because the alarm self-reset. The refrigerator contains 12 RBC units, including 4 O-negative units. The ambient temperature was normal. The units returned to 4°C by 03:30. The refrigerator's continuous QC was acceptable before and after the event, and no units were out of the refrigerator. The medical director must decide whether to release the units and what follow-up is needed.
1. Are the RBC units still acceptable for transfusion?
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RBCs are stored at 1-6°C. An excursion above 6°C but not above 10°C for less than 24 hours may be acceptable under AABB standards if the units are reviewed, visually inspected, and the event is documented. An exposure to 8.2°C for 45 minutes falls within that allowance. Quarantine the units during review, confirm that the actual temperature did not exceed 10°C, inspect for hemolysis or discoloration, and release with medical director approval. Discard if the temperature exceeded 10°C or the duration exceeded 24 hours, or if institutional policy is stricter.
2. What quality system follow-up is required?
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Open an incident report and perform a root-cause analysis. The immediate cause was failure to relocate units after an alarm; contributing causes may include alarm delay, inadequate on-call training, or lack of remote monitoring. Implement corrective actions such as alarm testing, staff retraining, after-hours response drills, and remote temperature notification. Verify effectiveness and document the CAPA. Review whether other refrigerators have the same vulnerability.