By Gina Shaw
Transitioning oversight of Rho(D) immune globulin (RhIG) from the blood bank to the pharmacy led to improved safety, timeliness, and standardization of postpartum dosing, according to new data presented at the ASHP 2025 Midyear Clinical Meeting & Exhibition, in Las Vegas.
RhIG, a biologic used to prevent Rh alloimmunization in pregnancy, has long occupied a regulatory gray zone. Although the FDA categorizes it under “blood and biologics,” some organizations handle it as a blood product and others as a drug. This variation has produced widely inconsistent dispensing practices across U.S. health systems.
At University Hospitals Cleveland Medical Center, RhIG was historically dispensed through the blood bank using a paper-based process submitted by the provider to the blood bank, explained presenting author Rebecca Powell, PharmD, BCPS, a clinical pharmacist specialist. “Because additional testing is required for some patients, the blood bank would wait until all testing was completed prior to sending the patient-specific dose. Since the majority of patients do not need more than the standard prophylaxis dose, this process delayed initial administration for all patients in order to provide a full dose for the few that needed more than the prophylactic dose.”
Best practice calls for RhIG administration within 72 hours after delivery. Under the old workflow, documentation was difficult to track because RhIG was not built into the electronic health record (EHR) as a medication, so dosing or billing errors could easily occur. “It was really hard to find documentation of the doses given, how much was given, and whether we were appropriately capturing the charge for the product,” Dr. Powell said.
When University Hospitals transitioned to a new EHR in October 2023, a multidisciplinary team from obstetrics, pharmacy, the blood bank, and information technology took the opportunity to shift RhIG oversight to pharmacy. The change was implemented to coincide with the go-live date for the EHR, and the new system incorporated order sets and clinical calculators to help prescribers and pharmacists identify eligible patients, determine the correct dose, and verify follow-up dosing when needed.
Educational outreach was extensive. “Since our nurses had previously been primarily responsible for identifying patients, it took a lot of education for providers and pharmacists on who qualifies, how to determine dosing, and how to use the RhIG calculator in the EMR [electronic medical record],” Dr. Powell said.
A post-implementation quality review from October 2023 through February 2025 evaluated 210 patients. Accurate identification of patients requiring RhIG was achieved in 99.5% of cases, and all qualified patients received the drug within 72 hours of birth. The median time from birth to administration was 18.9 hours. “Everyone was getting RhIG appropriately,” Dr. Powell said. “Only one patient missed a dose, which was due to a documentation error that we identified and reeducated on.” No patients received RhIG unnecessarily, an important finding for both cost and safety, she added.
Overcoming Resistance
There was some initial hesitation to transition RhIG to pharmacy oversight, Dr. Powell noted. “People were nervous about making sure that patients received the dose and about potential adverse side effects, which are minimal,” she said. “We didn’t see any safety events with our patients. There was also concern about ensuring the correct dose was given, but we evaluated all the doses and confirmed accuracy in every case.”
That resistance gradually gave way to recognition of the benefits. “I think there was a lot of transitional hesitation, and possibly some preconceived notions about barriers,” Dr. Powell said. “Ultimately, this created a lot of good educational opportunities for our teams. We had to make sure providers were aware of the new process and how to identify eligible patients. And for pharmacy, it meant reinforcing who qualifies, how we determine dosing, how to identify follow-up dosing, and how to use the RhIG calculator in the EMR to determine what the patient would qualify for after their initial dose.”
University Hospitals continues to refine its approach, including addressing RhIG product shortages and evaluating formulary options for cost efficiency, Dr. Powell noted.
As for lessons learned, “there are several takeaways,” she said. “Interdisciplinary engagement, leveraging the EHR to optimize ordering and verification, and continuous education for all stakeholders were key to making this transition successful.”
Dr. Powell reported no relevant financial disclosures.