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POLICY FOR THE TRANSFUSION OF BLOOD AND BLOOD COMPONENTS of 48 Version No. 6.0

POLICY FOR THE TRANSFUSION OF BLOOD AND BLOOD COMPONENTS

Document Author Authorised

Written By: Transfusion Practitioner / Transfusion Laboratory Manager Date: November 2018

Authorised By: Chief Executive

Date: 12th February 2019

Lead Director: Clinical Director, Clinical Support, Cancer and Diagnostic Services

Effective Date: 12th February 2019

Review Date: 11th February 2022

Approval at: Policy Management Sub-Committee

Date Approved: 12th February 2019


DOCUMENT HISTORY (Procedural document version numbering convention will follow the following format. Whole numbers for approved versions, e.g. 1.0, 2.0, 3.0 etc. With decimals being used to represent the current working draft version, e.g. 1.1, 1.2, 1.3, 1.4 etc. For example, when writing a procedural document for the first time – the initial draft will be version 0.1)

Date of Issue Version

No. Date

Approved Director Responsible

for Change Nature of Change

Ratification / Approval

19.09.12 4 19.09.12 AD Acute Directorate Draft 19.09.12

10.06.15 4.1 CD Hospital & Ambulance

Draft


Review Clinical Standards Group


Approval Policy Management Group

06.11.15 4.3 Clinical Director, Clinical Support, Cancer and Diagnostic Services

Ratification Clinical Standards Group

17.11.15 5.0 17/11/2015 Clinical Director, Clinical Support, Cancer and Diagnostic Services

Approval Policy Management Group

11.07.17 5.0 11.07.15 Clinical Director, Clinical Support, Cancer and Diagnostic Services

Slight amendments to current policy approved

Corporate Governance & Risk Sub-Committee

02/11/18 5.1 Clinical Director, Clinical Support, Cancer and Diagnostic Services

Slight amendments to wording to make less likely for misinterpretation

30/11/18 5.1 Clinical Director, Clinical Support, Cancer and Diagnostic Services

Endorsed at Clinical Standards Group

12/02/2019 6.0 12/02/2019 Clinical Director, Clinical Support, Cancer and Diagnostic Services

Approved at Policy Management Sub-Committee

NB This policy relates to the Isle of Wight NHS Trust hereafter referred to as the Trust


Contents 1 Executive Summary ....................................................................................................... 4

2 Introduction .................................................................................................................... 5

3 Definitions ...................................................................................................................... 5

4 Scope ............................................................................................................................. 7

5 Purpose ......................................................................................................................... 7

6 Roles and Responsibilities ............................................................................................. 7

7 Policy detail/Course of Action ....................................................................................... 11

8 Consultation ................................................................................................................. 25

9 Training ........................................................................................................................ 25

10 Monitoring Compliance and Effectiveness .................................................................... 25

11 Links to other Organisational Documents ..................................................................... 26

12 References ................................................................................................................... 26

13 Appendices .................................................................................................................. 27


1 Executive Summary 1.1 The transfusion of blood and blood components is an important, often lifesaving, part

of the treatment of many patients. It is also a procedure that has an element of risk, with errors potentially leading to the death of or long term damage to a patient who receives the wrong blood. The Trust therefore attaches the utmost importance to the correct procedures for the transfusion of blood and blood components.

1.2 SHOT (Serious Hazards of Transfusion) data shown that nationally“ patient

identification failure” and incomplete checking, in the majority of cases, was the root cause of wrong components being transfused. This is a fundamental element in the transfusion process and the point at which a wrong transfusion can be prevented. ABO incompatible red cell transfusions caused by clinical errors in both collection and administration, or administration alone and errors relating to Wrong Blood in Tube (WBIT) potentially could have led to Incorrect Blood Component Transfused (ICBT). Such potentially fatal errors are preventable through consistent good practice, however audits of practice in transfusion have shown that simple preventative measures such as the patient wearing a correct ID Band, being asked to confirm their name and date of birth which is checked against the ID Band prior to procedures and labelling samples at the bedside are being overlooked.

1.3 Administering the wrong blood type is the most serious outcome of an error during

transfusions. Most of these incidents are due to failure of the final checks carried out at the patient’s bedside to positively identify the patient and verify the blood product to be transfused (NPSA 2006). This demonstrates the importance of correct and meticulous completion of all the steps in the transfusion process, particularly the final checks at the bedside, and not making any assumptions about the safety of the steps prior to this.

1.4 It is the shared responsibility of medical, phlebotomy, laboratory, portering and nursing

staff to ensure safe and reliable, prescribing, requesting, collection of samples, testing and issuing, transporting and administering of components. All parties must be aware of their roles and responsibilities and adhere to the safe practices outlined in this policy.

1.5 This policy sets out the local requirements of the Trust based on National and

European Regulations and Guidelines and must be used in conjunction with the following additional Trust’s policies / Guidelines:

Patient Identification Policy

Maximum Surgical Blood Ordering Schedule (MSBOS)

Special Blood Component Guidelines

Guidelines for the use of Platelets

Guidelines for the use of Fresh Frozen Plasma

Protocol for the Management of Major Haemorrhage and/or Trauma in Adults and Children

Guidelines for Peripheral Intravenous Cannula Care and Intravenous Drug Administration

Cannulation & Venepuncture Policy

Infection Control Policies

http://www.shotuk.org/


1.6 Compliance with the above policies, protocols and guidelines will decrease the risk of patient exposure to errors and is an important element of the risk management of patients in this Trust.

1.7 This policy will be regularly reviewed and updated by the Hospital Transfusion

Committee. Significant changes will require ratification by the appropriate governance committee.

1.8 The policy will be regularly reviewed in the light of current scientific evidence and

opinion.

2 Introduction

2.1 The transfusion of blood and blood components is an important, often lifesaving, part of the treatment of many patients. It is also a procedure that has an element of risk, with errors potentially leading to the death of or long term damage to a patient who receives the wrong blood. To ensure the right patient receives the right blood, strict checking procedures must be in place at each stage. Administering the wrong blood type (ABO incompatibility) is the most serious outcome of error during transfusions (Never Event). Most of these errors are due to the failure of the final identity checks carried out between the patient (at the patient's side) and the blood component to be transfused.

2.2 This policy advises all healthcare professionals, who are involved in the transfusion

process, of safe transfusion practice and is the shared responsibility of all staff involved in the various stages of the Transfusion Process.

2.3 Training is an essential aspect of safe transfusion, which is required for all staff

involved at all stages of the Transfusion Process. 2.4 The clinical benefits to the patient being transfused should outweigh the potential risks,

the most important of these being acute haemolytic reactions, transfusion-transmitted infections and human error (especially at sample collection and labelling of pre-transfusion samples). Stringent procedures must be followed to ensure that the correct blood component is given and that any adverse reactions are dealt with promptly and efficiently.

3 Definitions Authorised Health Care Professionals – staff that have completed the “Non-Medical

Authorisation of Blood Products” course and have been assessed as competent to authorise blood products.

Blood / Blood Components: Red cells (RBC), Platelets (PLT), Fresh Frozen Plasma (FFP) and or Cryoprecipitate (CRYO) hereafter referred to as “Components” within this document.

BSQR – Blood Safety & Quality Regulations (2005): EU Directives - 2002/98/EC and 2004/33/EC have been transposed into UK law through the Blood Safety and Quality Regulations 2005 (Statutory Instruments 2005/50, 2005/1098 and 2006/2013). The


regulations came into force on 8 February 2005 and were implemented on 8 November 2005.

DATIX – Trusts electronic incident reporting system.

G&S – Group and Save: A blood sample that has been grouped and screened for alloantibodies but compatible red blood cells have not been cross matched. A G&S sample is valid for seven days provided the patient has not been transfused or had a sensitising event within the past three months.

HTC – Hospital Transfusion Committee

HTT – Hospital Transfusion Team

LIMS – Laboratory Information Management System

MHRA – Medicines and Healthcare products Regulatory Agency. Competent Authority for blood safety

NPSA – National Patients Safety Agency (Now part of NHS England)

Never Event - Serious, largely preventable patient safety incident that should not occur if the available preventative measures have been implemented

NHSBT – NHS Blood & Transplant

PCC – Prothrombin Complex Concentrate. Concentrated coagulation factors. Dosage

and duration depends on the severity of the condition and on the patient’s clinical condition together with laboratory results and the location and severity of the bleeding. Should be administered intravenously at no more than 3 IU per Kg body weight per minute.

PID – Patient Identifiable Data

Q Pulse – Laboratory Electronic Quality Management system.

SABRE – Serious Adverse Blood Reactions & Events – MHRA “Adverse Incident” reporting system.

SAE – Serious Adverse Event

SAR – Serious Adverse Reaction.

SHOT – Serious Hazards of Transfusion

WBIT – Wrong Blood in tube

XM – Crossmatch: A blood sample that has been grouped and screened for alloantibodies against which donor red blood cells have been serologically cross matched.

https://www.medicines.org.uk/emc/medicine/21147


4 Scope 4.1 This policy applies to all healthcare professionals within the Trust who are involved

both directly and indirectly with the transfusion process and will affect the safety and well-being of patients.

5 Purpose 5.1 Due to the high regulatory standards set out in the Blood Safety and Quality

Regulations, 2005 (BSQR’s), monitored by the Medicines and Healthcare products Regulatory Agency (MHRA) it is paramount that staff are trained adequately and competency assessed. This policy, based on national guidelines is intended to give clear instructions on the correct procedures to be followed by all staff members involved at any stage of the transfusion process to ensure that the right patient receives the right blood component at the right time.

6 Roles and Responsibilities 6.1 Trust Board is legally responsible under the provisions of the Blood Safety & Quality

Regulations (2005) (BSQR’s) to ensure that there are policies and procedures in place to manage all transfusion processes.

6.2 Medical staff or other authorised Health Care Professionals are responsible for:

Ensuring they are trained and assessed as competent in the skills they undertake in relation to the transfusion process.

Evaluating the clinical need for the transfusion of blood / blood components taking into consideration any alternatives to transfusion and having fully explained the risks and benefits to the patient including obtaining consent.

Prescribing components, taking into consideration the patients requirements in respect of the need for any Special Blood Components (see Guidelines for Special Blood Components) and the recommendations of the Maximum Surgical Blood Ordering Schedule (MSBOS).

Responding to transfusion laboratory requests for additional samples as required e.g. to verify patient’s blood group if a historical group is not held on the Laboratory Information Management System (LIMS).

Fully documenting the transfusion episode in the patient’s Medical Records and on the Blood Transfusion Chart including the reason for the request and any special blood component requirements.

Ensuring that, if the patient is transferred from their care, a full handover to the receiving medical staff is undertaken, including details of any components already requested or required.


Requesting components, ensuring that all sample labelling is in accordance with this Policy. If a “telephone request”, ensure the order number is recorded against the transfusion episode in the patient’s Medical Records and on the Blood Transfusion Chart.

Taking and labelling of blood samples for laboratory testing in accordance with this Policy.

Management of any suspected Adverse Transfusion Reactions (ATR’s).

Administering components and recording all necessary information on the Blood Transfusion Chart.

Monitoring patients, including taking observations during transfusion and carrying out the appropriate actions in the event of adverse transfusion reactions.

6.3 Nursing staff are responsible for:


Ensuring that the patient is wearing an accurate and legible ID band at all times during the transfusion process. (See Patient Identification Policy).

Taking and labelling blood samples for laboratory testing in accordance with this Policy.

Receiving and recording receipt of the component in the Clinical area by either use

of the electronic system or by paper receipt.

Preparing the patient for Transfusion.

Administering components and recording all necessary information on the Blood Transfusion Chart and by inputting data into the electronic system if in use.

Monitoring patients, including taking observations during transfusion and carrying out the appropriate actions in the event of adverse transfusion reactions.

Reporting of suspected transfusion reactions or other related incidents, to the medical staff or other appropriately trained & competent Health Care Professional.

Completing the audit trail by recording the transfusion episode outcome via the electronic system if in use, or by paper record and returning it to the Blood Transfusion Laboratory as soon as possible.

Ensuring that transfusion of components is commenced within 30 minutes of receipt or components are returned to the Blood Transfusion Laboratory within 30 minutes if not required

Informing Blood Transfusion Laboratory staff of any components which have not been transfused and have been discarded in the clinical area.


Actioning requests from the Transfusion Laboratory in response to any recall procedure being instigated and responding to any further action required.

6.4 Phlebotomy staff responsibilities are restricted to:


Taking and labelling of blood samples for laboratory testing in accordance with the Trust’s Policy.

6.5 Hospital Blood Transfusion Laboratory staff are responsible for:

Ensuring they are trained and assessed as competent in the skills they undertake

in relation to the transfusion process.

Checking that the labelling of request forms and blood samples comply with this policy and the Trust’s “Patient Identification Policy”.

Providing an “order number” to a medical officer or other authorised Health Care Professional who is requesting components via telephone.

Blood grouping, antibody screening and cross matching of samples. Including any additional investigations and requesting any additional samples deemed necessary.

Labelling and issuing blood and blood components.

Traceability, ensuring there is a full audit trail recorded electronically or by a paper based system.

Investigating and reporting of suspected Serious Adverse Events and Reactions (SAE & SAR’s), reporting to SHOT / SABRE as necessary.

Initiating/actioning component recall procedures in response to a recall being initiated externally (e.g. NHSBT) or internally.

6.6 Porterage staff and Hospital Transport Drivers responsibilities are restricted to:

Ensuring they are trained and assessed as competent in the skills they undertake

in relation to the transfusion process.

Collection and delivery of samples and request forms.

Completion of the Blood Collection Slip which must include the patient’s full name, date of birth and IW number.

Removal of components through the electronic blood tracking system and delivery to the clinical area in a timely manner, ensuring receipt at the clinical area is recorded.


Return of components to the Issue Refrigerator or Blood Transfusion Laboratory via the electronic blood tracking system as soon as possible if necessary.

6.7 Ward / Departmental Managers and Clinical Leads are responsible for ensuring that all staff working within their areas:

Have completed training in “Safe Transfusion Practice” by completing the “on-line” module on a yearly basis.

Are assessed as competent in the skills they use as part of the Transfusion Process by completing the National Patient Safety Agency (NPSA) Competency Assessments (available on the Intranet) on a 2 yearly basis or by the completion of the “on-line” competency assessment on the Trusts’ e-learning module.

6.8 Hospital Transfusion Team (HTT) is responsible for:

Writing and/or reviewing transfusion policies and procedures, ensuing that they are fit for purpose and referring them to the HTC for approval.

Reviewing the arrangements for training of staff in transfusion policies and procedures.

Reviewing serious adverse events and reactions, including near misses and reporting findings to the HTC and externally to SHOT/SABRE as applicable.

Reviewing the appropriateness of blood transfusion and making recommendations about the proper use of components and reporting findings to the HTC.

Recommending corrective action in transfusion practice, where indicated.

Reviewing new evidence and best practice guidelines around transfusion, the efficient use of components or alternatives to transfusion and making recommendations to the HTC.

Providing assurance to the HTC that systems are in place to minimise risk to patients.

Ensuring that new evidence and practice from national reports and guidance are implemented.

Providing continued education in transfusion medicine for all relevant members of staff.

6.9 Hospital Transfusion Committee (HTC) is responsible for:

Reviewing transfusion policies and procedures as referred from the HTT.

Reviewing the arrangements for training of staff in transfusion policies and procedures.


Reviewing serious adverse events and reactions, including near misses as referred by the HTT.

Reviewing the appropriateness of blood transfusion and making recommendations about the proper use of components.

Recommending corrective action in transfusion practice, where indicated.

Reviewing new evidence and best practice guidelines referred by the HTT around transfusion, the efficient use of components or alternatives to transfusion and making recommendations for implementation.

Ensuring that recommendations, based on new evidence and practice, from national reports and guidance are implemented

.

Providing assurance to the Trust Board that systems are in place to minimise risk to patients.

Promoting continued education in transfusion medicine for all relevant members of staff.

7 Policy detail/Course of Action 7.1 Collection and Labelling of Blood Samples for Pre Transfusion Testing. 7.1.1 Request Form

Request forms MUST be clearly completed in legible handwriting. Addressograph

labels may be used on the request forms only and MUST be attached to ALL copies of any multi-part forms. Addressograph labels MUST be clear and without alteration. The form MUST be signed by the requesting medical officer or other authorised Health Care Professional.

Requests for G&S MUST be made on a Blood Sciences request form.

Requests for Cross matched red cells MUST be made on the “Blood Transfusion Crossmatch Request” form unless a telephone request is made.

7.1.2 Samples

Samples MUST be collected and labelled as one uninterrupted process involving one member of staff and one patient. One patient must be completed before commencing any further patients.

The staff member collecting the sample MUST ensure that they have positively identified the patient immediately prior to collection by the use of ‘open’


questioning i.e. by asking the patient to state their full name and date of birth . Identification details provided by the patient MUST then be checked / confirmed against the patient’s ID band and request form (it is acceptable to confirm by documentation only in an outpatient setting).

Children, patients suffering from dementia or the unconscious or sedated must be identified by the information on their ID band only. Refer to The Trust’s “Policy for Patient Identification”.

Sample labelling must be completed by the staff member taking the sample.

The sample label must be completed immediately after collection, not remotely or prior to the procedure.

All samples MUST be completed accurately in legible handwriting without

alteration using indelible ink or by using a label produced by the electronic blood tracking system which uses the patient’s ID band barcode the together with the staff members identification barcode.

o A staff identification barcode MUST ONLY be used by the person it

was issued to.

o NO other Addressograph or electronically printed labels are acceptable on samples.

The Blood Transfusion Laboratory cannot accept inadequately or inaccurately labelled samples. (See Organisation’s Patient Identification Policy).

The minimal acceptable labelling requirements on samples are: o Surname o Forename (for unnamed infants use MI or FI). o Date of Birth o Hospital No: “IW Number” or Unique ‘U’ or ‘E’ Number

‘U’ Numbers will be issued by ED in the event of a computer failure.

‘E’ Numbers will be issued in the event of a Major Incident o Signature of person taking the sample o Date of collection

For emergency admissions of ‘unknown’ patients, the minimal acceptable labelling requirements are:

o Surname: “Unknown” o Forename: “Female” or “Male” o Hospital No: “IW Number” or Unique ‘U’ or ‘E’ Number o Signature of person taking the sample o Date of collection

7.1.3 Two sample rule:


A second sample will be requested by Transfusion Laboratory staff to confirm the ABO group of any patient requiring blood components who has a current sample in the laboratory but has no historical group recorded on the LIMS.

The second sample MUST be taken independently of the original sample.

In an urgent situation only group O red cells will be issued until the second sample has been processed.

Note: for neonates/children for whom it is not possible to obtain a second sample in an urgent situation, group specific red cells will be issued after a second group check on the original sample.

7.1.4 Timing of sample collection for pre-transfusion testing

To ensure that the blood sample used for cross matching is representative of a patient’s current immune status the following timings for sample collection are required:

Patient Type Sample Storage at 2

o – 8

oC (once tested)

Patient transfused or pregnant in last 3 months

Sample valid up to 3 days*

Patient NOT transfused or NOT pregnant in last 3 months Sample valid Up to 7 days

*This is the time between the sample being taken and the subsequent transfusion

Note: For routine crossmatches, samples should ideally be taken 5-6 days before the date red cells are required.

Where the patient has been transfused or pregnant within the preceding three months or when such information is uncertain or unavailable, a sample should be collected no more than 48 hours in advance of the actual transfusion. The transfusion should ideally be completed within 72 hours of sample collection.

7.2 Requesting Blood and Blood Components.

It should be remembered that any patient has the right to refuse any transfusion of blood components. This should be clearly documented in the patient’s Medical Records / consent forms. This applies to all patients at any stage of the transfusion process. (See Appendix F: Guidance relating to Jehovah’s Witnesses).

Non-essential and “out of hours” requests for transfusion and overnight administration of blood components should be avoided wherever possible because of the increased risk of errors.


7.2.1 Routine Requests (over 24hrs)

Red cells

Requests for transfusions MUST be made by a medical officer or other authorised Health Care Professional by:

o Completing the “Blood Transfusion Crossmatch Request” form and

should be made at least 24 hrs in advance of the intended transfusion o Contacting the Blood Transfusion Laboratory and making a telephone

request. If a G&S has been taken then a telephone request MUST be made

For ALL telephone requests, the Blood Transfusion Laboratory staff will give the requesting medical officer or other authorised Health Care Professional an “order number” to confirm the request. The requestor MUST write this number in the patient’s Medical Records and Blood Transfusion Chart together with the reason for transfusion.

All requests for blood components MUST give full patient identification details, including: o Surname o Forename

o Date of Birth o IW Number

The full indication for the request MUST be provided including the underlying

cause (or condition) that necessitated the transfusion.

Details of the quantity and type of component required including any special requirements and the time and date it is required MUST be stated.

The location of the patient at the time of the request MUST be stated together with the location where the blood components are to be given (if different).

Clinical details, giving information about the patient’s diagnosis should be provided, wherever possible including any past obstetric and transfusion history.

Other Components (e.g. Platelets (PLT), Fresh Frozen Plasma (FFP), Cryoprecipitate (CRYO), Prothrombin Complex Concentrate (PCC)

A telephone request MUST be made by a Medical Officer or other authorised Health Care Professional in the event of other components being required.

7.2.2 Urgent Requests (Within 24hrs)

If the transfusion is required URGENTLY or within 24 hrs the requesting practitioner MUST ring the Blood Transfusion Laboratory and make a Telephone Request. (See the Trust’s Major Haemorrhage protocol)


7.3 Consent for Transfusion

It is the sole responsibility of Medical Staff or other authorised Health Care

Professional to obtain a “valid consent” for the transfusion. As with any emergency treatment, the need for consent must not prevent or delay essential urgent transfusion, but the presence of a valid Advance Decision Document declining transfusion should always be respected.

The patient MUST be fully informed of the risks, concerns and any alternative therapies. This information MUST be recorded on the Blood Transfusion Chart and in the patient’s Medical Records. Leaflets “Will I need a Blood Transfusion / Platelets” are available from the Transfusion Practitioner or via the Intranet.

Patients transfused when it is not possible to obtain consent prior to transfusion should be provided with information retrospectively. This is important as transfused patients are no longer eligible to act as blood donors. For the same reason, patients who have given consent for possible transfusion during surgery should be informed if they actually received blood while under anaesthesia. A leaflet “Unexpected Transfusion” is available from the Transfusion Practitioner.

Patients needing long-term transfusion support should have a modified form of consent. Consent is not required for each transfusion episode providing consent has been clearly documented within the past year.

For paediatric patients, the parents must give a “valid consent” to the transfusion and should be fully informed of the risks, concerns and any alternative therapies. Consent should be clearly documented on the Blood Transfusion Chart and within the patient’s Medical Records. A leaflet “A Parent’s Guide to Transfusion” is available from the Transfusion Practitioner.

7.4 Prescription of Components

It is the sole responsibility of Medical Staff or other authorised Health Care Professional to prescribe blood or blood components.

It is essential that all the following patient identification details be recorded on the Blood Transfusion Chart:

o Surname o Forename o Date of Birth o IW Number

The justification for the transfusion MUST be documented in both the patient’s Medical Records and on the Blood Transfusion Chart prior to the transfusion commencing. When prescribing, Medical Staff or other authorised Health Care Professional should be mindful of the TACO Checklist on the Blood Transfusion Chart and if in doubt refer to the Consultant Haematologist. The prescription must specify:

o The type of component to be administered, including any special requirements e.g. Irradiated, CMV negative, Emergency O Negative


Blood or “Other” i.e. washed cells etc. (See Guidelines for Special Blood Requirements).

o Number of Units / Quantity to be given o Duration of transfusion. (Up to maximum permitted time)

o Any special instructions, e.g. any medication required before or during

the transfusion

o Wherever possible, routine transfusions should not be carried out at night (between 22:00 & 06:00) where reduced Nursing Staff and/or reduced lighting may contribute to a Transfusion Reaction being missed. Where the patient’s condition clinically indicates a transfusion overnight, care must be taken that the patient is strictly monitored to ensure that a Transfusion Reaction is noted immediately. When the decision to transfuse is made, it is imperative that the prescriber considers all risks to the patient and that any steps to reduce that risk must be taken.

7.5 Collection and Delivery of Components

7.5.1 Only staff trained and assessed as competent in using the electronic blood track kiosk are permitted to access the Issue Fridge. Access is controlled by use of individualised bar-coded ID cards. Under no circumstances must ID cards be lent / borrowed between staff or given to untrained staff.

7.5.2 Only components for ONE patient MUST be removed from the Issue Fridge at

a time. Collecting components for more than one patient at the same time is NOT PERMITTED

7.5.3 The person collecting the blood MUST have documentation specifying the

patient identification details which MUST be checked against the patient identification displayed by the electronic blood track kiosk This will be one of the following:

Patient’s Medical Records

Blood Transfusion Report

Blood Transfusion Chart

Blood Collection Slip (This may be relayed by telephone message)

7.5.4 The following details MUST match:

Surname

Forename

Date of Birth

IW Number

7.5.5. The donation number on the unit must match the donation number on the compatibility label. Any discrepancy must be bought to the attention of a member of Blood Transfusion Laboratory staff.

7.5.6 All components MUST be removed by scanning the component unit number

via the electronic blood track system. IT IS NOT PERMISSABLE for ANY


component to be removed from the Issue Room without first scanning through the system unless otherwise instructed by Laboratory Staff.

7.5.7 It is important that the compatibility label is date / time stamped prior to

removing the component from the Blood Issue Room unless electronic blood tracking compatibility labels are in use.

7.5.8 Red blood cells (RBC’S) MUST be stored in a designated, purpose built Blood

Transfusion Laboratory Refrigerator at 4oC. Under no circumstances MUST they be placed in a domestic refrigerator.

Single red cell units should be transported in a red “Blood Component Transit Bag”. Once removed from the Blood Issue Fridge, collected units must be delivered directly to the clinical area. If red cells have been received in the clinical area but a decision made not to transfuse for any reason they MUST be returned to the Issue Fridge WITHIN 30 minutes of removal.

Multiple units of red cells MUST be transported in a sealed cold box. Sealed cold boxes are validated for 4 hours. Cold Boxes MUST be packed in accordance with the instructions in the Blood Issue Room. Once packed and sealed, the cold box MUST be delivered directly to the clinical area and if not required MUST be returned unopened to the Issue Fridge WITHIN four hours of removal.

Red cells issued in a sealed cold box MUST be transfused or returned within the 4 hour period. Once sealed, the box should not be opened unless required. Once opened, the cold chain has been broken and the red cells must be transfused within 4 hours or returned to the Issue Fridge within 30 minutes.

Red cells for transfer to another hospital MUST be sealed in a cold box and not be opened unless required. Requesting Medical Officers MUST inform the Blood Transfusion Laboratory of the intention to transfer Blood Components to another hospital BEFORE removal from the Issue Fridge.

7.5.9 Platelets (PLTS) MUST NOT be refrigerated; they MUST be stored in a

Platelet Incubator at 22oC and should be transported in a Blood Component Transit Bag at ambient room temperature.

7.5.10 Fresh Frozen Plasma (FFP) is stored deep frozen below -25oC. Once

thawed, they should be transported at ambient temperature in a Blood Component Transit Bag. Multiple units of FFP for the same patient may be carried in the same transit bag.

7.5.11 Cryoprecipitate (CRYO) is stored deep frozen below -25oC. Once thawed,

MUST be transported in a Blood Component Transit Bag at ambient temperature and MUST NOT be refrigerated once thawed. Multiple units of CRYO for the same patient may be carried in the same transit bag.

7.6 Receipt of Components


7.6.1 If the blood components are in a sealed cold box, the box should NOT be opened until the contents are required at which point the contents should be checked.

7.6.2. For all blood components in Blood Component Transit Bags, on arrival in the

clinical area, a trained member of staff (medical practitioner, registered nurse, operating department practitioner/ assistant) MUST examine the unit and check:

The component details correspond with the Compatibility Label attached to the component. This will carry the following information:

o Surname o Forename o Date of Birth o IW Number o Donation Number o Blood Group o Expiry date of unit o Integrity of the pack o Any unusual colour, turbidity (sediment or particles), or clumping of the

contents

7.6.3. The Compatibility label MUST be completed with the time & date of arrival in the clinical area, together with the receiver’s signature.

7.6.4. If in use, the electronic tracking system should be used to receipt the unit

on the clinical area by scanning the barcode on the electronic Compatibility Label together with the identification barcode of the member of staff.

7.6.5. The Compatibility Label MUST remain attached to the component

throughout the transfusion.

7.6.6. Transfusion of components should commence within 30 minutes of receipt in the clinical area.

7.6.7. If red cells have been received in the clinical area but transfusion not

started within 30 minutes of receipt and the component is subsequently required for transfusion the unit MAY remain on the ward but MUST be transfused within 3.5 hours (e.g. 30 minutes + 3.5 hours = Total 4 hours).

7.7 Return of Blood Components

7.7.1. If the transfusion of components cannot be commenced within 30 minutes or is no longer required for transfusion, the component should be returned immediately to the Transfusion Laboratory by trained staff and scanned through the electronic blood tracking system.

7.7.2. The electronic blood tracking system will “Alert” if the component has been

out of temperature control for over 30 minutes. If the electronic blood tracking system “alerts” then Blood Transfusion Laboratory staff MUST be informed and the component handed directly to them.


7.7.3. On returning Red Cells and FFP, they should be placed into the Issue Fridge. (Unless they have been out of temperature control for over 30 minutes in which case the electronic blood tracking system will “Alert” and the component handed directly to the Blood Transfusion Laboratory staff).

7.7.3. Under NO circumstances must Platelets and Cryoprecipitate be placed in

the Issue Fridge. All such units returned MUST be scanned through the electronic blood tracking system and then handed directly to the Blood Transfusion Laboratory staff.

7.8 Preparation of the Patient

7.8.1 If possible the procedure MUST be explained to the patient and consent obtained. The NHS information sheet “Receiving a Blood Transfusion” is available from the Transfusion Practitioner if required.

N.B. Jehovah’s Witnesses will be identified by a RED clasp on the wristband. Ensure all red wristband clasps are identified as to the reason they are in place and acted on accordingly.

7.8.2 Prior to requesting collection of components from the Issue Fridge, ensure

adequate venous access is in situ.

7.8.3. Prior to commencing the transfusion, obtain baseline vital signs, including:-

Temperature

Pulse

Respiration

Blood Pressure

7.8.4. The patient MUST also be questioned about any symptoms such as chills,

itching, rashes, muscle aches or difficulty in breathing prior to the transfusion commencing as these symptoms may be mistaken for a transfusion reaction.

7.8.5 The patient MUST be able to be observed at all times in a safe clinical

environment and made as comfortable as possible.

7.8.6 Pre-medication of the patient may be required in certain circumstances which will be identified by the clinicians.

7.9 Pre-Infusion Checks.

7.9.1 There MUST be a fully completed Blood Transfusion Chart which has been signed and dated by the medical staff or other authorised Health Care Professional detailing:

The patients, Forename, Surname, Date of Birth and IW Number

The number and type of component to be transfused over a specified time

Any special requirements e.g. CMV Negative / Irradiated Units

Any concomitant drugs / premedication required


7.9.2 Prepare the following equipment:

Sterile blood administration set primed with normal saline 0.9%.

Gloves (non-sterile) must be worn when handling blood and blood components.

A volumetric infusion pump with dedicated giving set which has been specifically identified as being suitable for blood transfusion by the manufacturer should be used and wherever possible. The use of gravity fed drips MUST be avoided.

Blood Components MUST be transfused by a separate intravenous route from all other infusions. No other solutions / drugs MUST be added directly to any blood component. If a multiple lumen venous catheter is in situ, this may be used, one lumen must be solely used for blood transfusion.

In exceptional circumstances, where it is not possible to have more than one intravenous access point and where withholding a drug could be deemed detrimental, the transfusion should be stopped briefly and a double lumen needle free device with an anti-reflux valve fitted. This should be flushed prior to recommencing the transfusion with Normal Saline (Sodium chloride 0.9%). (Opioid PCA system must be given via a non-return valve).

Blood Components MUST be infused through a blood giving set fitted with a 200 micron filter. The giving set MUST be changed:

o At least 12 hourly o After every 3 components infused o If different ABO groups are given o If different components are given

If IV set requires priming, then ONLY Normal Saline (Sodium chloride 0.9%) MUST be used.

A blood warmer should be used if a large volume transfusion is given in a short time e.g. more than 50mL/ Kg / per hour or 1 unit per 10 minutes in an adult or if advised by the Blood Transfusion Laboratory. Blood MUST NOT be warmed by any other means.

7.9.3 The Patient MUST be wearing an ID Band with their correct details printed / written clearly on it. 7.9.4. Full PID check by asking the patient to confirm their name and date of birth

and confirming with the information on the ID Band. Identify any red clasps on the ID Band and ensure blood or blood components are not contraindicated. Patients with Advanced Directives, Jehovah’s Witnesses or other religious groups who refuse the transfusion of blood products, will be identified by a red clasp on their wristband and their medical records annotated accordingly. (see Patient Identification Policy)

7.9.5. Prior to administration, the component MUST be examined, checked and


cross-checked against the Blood Transfusion Chart, Compatibility Label and the ID Band, for the following:

Correct ABO / Rhesus Group. (See Appendix B1 for NHSBT Component Label)

Expiry date of unit on the NHSBT Component Label. (Unless a specific expiry time is stated the component expires at 23:59 on the date shown on the pack label). (See Appendix B1 for NHSBT Component Label)

The component label matches any special requirements (CMV Negative / Irradiated) which have been requested by the clinician. ( See Appendix B1 for NHSBT Component Label and Appendix B2 for NHSBT Irradiation Indicator Label)

Integrity of the pack.

Any unusual colour, turbidity (sediment or particles), or clumping of the contents.

7.9.6. If there are ANY discrepancies the unit MUST NOT be transfused until the

discrepancy has been resolved and the Blood Transfusion Laboratory staff / Transfusion Practitioner contacted for advice.

7.9.7. Ensure an appropriate care plan is written for the patient.

7.10 Blood Administration

Non-essential and “out of hours” / overnight administration of blood components should be avoided wherever possible because of the increased risk of errors, unless clinically indicated

7.10.1 All checks MUST be performed at the bedside. 7.10.2 Components issued from the Blood Transfusion Laboratory MUST have a Compatibility Label (see Appendix C1 and / or C2) firmly attached. This MUST carry the following information:

Donor unit number and donor blood group

Surname

Forename(s)

IW Number

Date of Birth

Patients’ Blood Group 7.10.3. Identification of components and the recipient MUST be carried out by two

members of staff, one of whom must be a Medical Practitioner, or holding current registration of the UKCC Professional Register as a Registered Nurse (RGN) / Midwife (RM) / Sick Children’s Nurse (RSCN), or Operating Department Practitioner / Assistant and will take responsibility for the checks and sign the Blood Transfusion Chart.


7.10.4. Positive Identification of the patient MUST be carried out before any component is transfused as per the Trust’s Patient Identification Policy. Children, patients suffering from dementia, the unconscious or sedated must be identified by the information on their ID Band. The following checks MUST be performed at the bedside:

Surname.

Forename(s)

IW Number

Date of Birth

7.10.5. Positive identification of the patient must be checked wherever possible, by asking the patient to state their:

Full Name (i.e. Surname and Forenames)

Date of Birth This MUST be checked and found to be identical with:-

Patient’s ID Band

Blood Transfusion Chart

Compatibility Label If there is any discrepancy with the PID it MUST be investigated before the transfusion is commenced.

7.10.6. The component label (Appendix B1) and Compatibility Label (Appendix C1

and C2) must be checked to ensure that the expiry date and the reservation date of the unit are valid. The expiry of the unit is at 23:59 on the date shown and the transfusion MUST be concluded by this time.

7.10.7 The blood group of the component MUST be compatible with that of the

patient as indicated on the Compatibility Label. If this is not the case, then the reason for the blood group difference will have been communicated. If no communication has been received then the discrepancy MUST be checked with the Blood Transfusion Laboratory before the transfusion is commenced.

7.10.8. The donor number on the component label (Appendix B1) must correspond

to that on the Compatibility Label (Appendix C1 and C2). If any discrepancy is found, advice MUST be sought from the Blood Transfusion Laboratory staff / Transfusion Practitioner as to what action should be taken.

7.10.9 Ensure the chosen IV cannula is patent or, if necessary take appropriate

action to ensure patency. If there is going to be a significant delay, blood components MUST be returned to the Blood Transfusion Laboratory without delay.

7.10.10 Connect blood administration set fitted with a 200micron filter to intravenous

cannula, secure as appropriate.

7.10.11 Commence the transfusion at the rate prescribed by the Medical Officer or other authorised Health Care Professional on the Blood Transfusion Chart.

7.10.12 The date and time of commencement MUST be documented on the Blood

Transfusion Chart.


7.10.13 Maintain a full fluid chart and accurately record urine output.

7.10.14 Closely monitor the patient (see Observation of Patient).

7.10.15 Immediately AFTER the transfusion is commenced the ‘peel off’ label on the “Compatibility Label” MUST be fixed to the Patient’s Blood Transfusion Chart. (see Appendix C1 and / or C2)

7.10.16 Transfusion of each unit of red cells should normally completed within two-

three hours of removal from the Issue Fridge or Cold Box, but no longer than maximum of four hours.

7.10.17. In all cases the transfusion MUST NOT exceed 4 hours duration. If the

transfusion is still incomplete after 4 hours have elapsed, the transfusion should be stopped, the unit taken down and any remaining component discarded.

7.10.18 Platelets should be infused over 30 minutes and as soon as possible after

removal from the Blood Issue Room.

7.10.19 FFP should be infused over 30 minutes and within four hours of removal from the Issue Fridge. If the FFP is kept in the Issue Fridge then it can be used up to 24 hours after thawing.

7.10.20 CRYO should be infused over 30 minutes and within four hours of thawing.

7.11 Observation of Patients Receiving Blood Transfusion

7.11.1 For each component given, the following observations must be monitored and recorded on the patients Observation chart (and additionally by entering onto the electronic blood tracking software via the handset if in use).

Immediately prior to transfusion: Temperature, B/P, Pulse & Respirations (Base Line)

After 15 minutes: Temperature, B/P, Pulse & Respirations

After 30 minutes: Temperature, B/P, Pulse & Respirations

Then hourly (if stable): Temperature, B/P, Pulse & Respirations 7.11.2 In patients MUST continue to be monitored every four hours for 24 hours after

the transfusion. If the patient is a “Day Case” then the patient MUST be given advice as to what to be aware of and they MUST be given a contact telephone number where they can obtain advice if they feel unwell after returning home.

7.11.3 Any change in the observations or if the patient develops pain at drip site,

chest pain, back pain, loin pain or a feeling of impending doom etc., must be reported immediately to medical staff. In any case of suspected transfusion reaction, the transfusion must be immediately stopped, medical staff informed and appropriate action initiated. Refer to “Action to Be Taken in All Cases of a Suspected Transfusion Reaction” which is available on the Intranet.

7.12 Completion of Transfusion


7.12.1 On completion of the transfusion, the “fate” of the component MUST be recorded on the compatibility label which should be returned to the Blood Transfusion Laboratory as soon as possible (unless the electronic tracking system is in use and the handset used).

7.12.2 The giving set should be removed and the intravenous cannula flushed with

prescribed normal saline. 7.12.3 Equipment MUST be disposed of safely in accordance with the control of

Infection policy (see IPC Safe Handling and Disposal of Sharps). The whole giving set should be discarded in the sharps bin.

7.12.4 Empty component packs should be sealed with a spigot, placed in a leak

proof plastic bag, and disposed as clinical waste by the ward staff.

7.12.5 Partly used components should not have the giving set removed. They must be placed in a leak-proof plastic container and disposed of as clinical waste by the ward staff.

7.12.6 If a moderate or severe transfusion reaction is suspected, the component

pack and giving set will be required for further investigation. The pack must be sealed with a sterile spigot to maintain sterility and returned to the Blood Transfusion Laboratory immediately in a leak-proof plastic container. This should be sent with a completed Blood Transfusion Reaction Form and appropriate samples as indicated on the form, and should be sealed in a separate plastic bag.

6.13 Recall

7.13.1 In the event of a recall being instigated the Transfusion Laboratory staff will follow the laboratory recall procedure. It is important that any components are located as soon as possible, are not transfused and are removed from use.

7.13.2 On occasions there may be the requirement for the recall of red cells, platelets, FFP or CRYO. This may be at the request of NHS Blood & Transplant (NHSBT) or internally initiated by the Blood Transfusion Laboratory in response to further information pertaining to the patient coming to light e.g. special requirements or if an error/ incident is discovered.

7.13.3 If the component is in a clinical area or “in transit”, the Transfusion Laboratory

will contact the clinical area and request the immediate return of the unit which MUST NOT be transfused and MUST returned to the Transfusion Laboratory immediately and handed to a member of the Transfusion Laboratory staff.

7.13.4 If the component is being transfused the transfusion MUST be stopped

immediately and taken down. The unit should be sealed with a sterile spigot, returned to the Blood Transfusion Laboratory in a leak proof container and handed to a member of Blood Transfusion Laboratory staff. The episode MUST be recorded on the Blood Transfusion Chart as “Part Transfusion” together with the amount transfused and annotated Product Recall


7.13.5 If the unit has been transfused in whole or in part, the Transfusion Laboratory will inform the Consultant Haematologist to decide any further action. The clinical area will be informed of any action that needs to be taken. The episode MUST be recorded in the patient’s medical notes and the Blood Transfusion chart relating to the episode MUST be annotated as Product Recall.

8 Consultation

8.1 This document is endorsed by the Hospital Transfusion Team and Hospital Transfusion Committee.

9 Training

9.1 This (Policy for the Transfusion of Blood & Blood Components) has a mandatory training requirement which is detailed in the Trusts mandatory training matrix and is reviewed on a yearly basis

10 Monitoring Compliance and Effectiveness

10.1 Monitoring of the policy is carried out as part of the timed planned programme of audits to ensure compliance.

10.2 The Transfusion Laboratory Manager/ Blood Sciences Quality Manager is

responsible for ensuring internal audits are carried out against ISO 15189:2012 / BSQR standards that monitor the transfusion process.

10.3 The Transfusion Practitioner is responsible for conducting National Comparative

audits and internal audits in Clinical areas against compliance with the policy. 10.4 All adverse clinical incidents /non-conformances are recorded:

Internally: Q Pulse / Datix

Externally: SHOT (Serious Hazards of Transfusion) / SABRE (MHRA) 10.5 All adverse clinical incidents /non-conformances are fully investigated, the outcome

recorded and Corrective and Preventative Action (CAPA) put in place 10.6 The HTT is responsible for reviewing serious adverse events and reactions, including

near misses and reporting findings to the HTC. 10.7 The HTC is responsible for reviewing serious adverse events and reactions, including

near misses as referred by the HTT and reporting to the Trust board. 10.8 The Transfusion Practitioner is responsible for monitoring the electronic blood

tracking system to identify operator errors in the transfusion process in Clinical areas, to investigate any errors and put effective CAPA in place.


10.9 The Training & Development Department is responsible for maintaining records of any Safe Transfusion Practice training carried out as part of the Trust’s Mandatory Training programme.

10.10 Ward / Clinical Department managers are responsible for recording and maintaining

records of staff within their area in regard to attendance of Safe Transfusion Practice Training and NPSA Competency Assessments.

11 Links to other Organisational Documents Aseptic Non Touch Technique (ANTT Policy)

Maximum Surgical Blood Ordering Schedule

Patient Identification Policy

Safe Handling and Disposal of Sharps

Training Tracker:

Blood Transfusion Safe Transfusion Practice Level 1 (Mandatory for all Clinical Staff)

Blood Transfusion – Level 2: Modules 1, 2 & 3)

B. Braun Infusomat Infusion Pump (Blood Use Only)

Consent Process - An Introduction

12 References Association of Anaesthetists of Great Britain and Ireland. 2008. Blood Transfusion and the

Anaesthetist; Red Cell Transfusion 2. British Committee for Standards in Haematology; Guidelines for the Administration of Blood

Components. December 2009 British Committee for Standards in Haematology; Guidelines for pre-transfusion

Compatibility in Blood Transfusion Laboratories. Transfusion Medicine, 2012, 23, 1, British Committee for Standards in Haematology: Guidelines for the Clinical Use of Red Cell

Transfusions. British Journal of Haematology, 2001 113 24 – 31 British Committee for Standards in Haematology: Guidelines for the use of fresh frozen

plasma, Cryoprecipitate and Cryosupernatant. British Journal of Haematology 2004, Vol126 1

British Committee for Standards in Haematology: Amendment to the guidelines for the use

of fresh frozen plasma, Cryoprecipitate and Cryosupernatant (selection according to ABO and RhD grouping.) 2005 BCSH Transfusion Task Force.


British Committee for Standards in Haematology: Guidelines for the Use of Platelet

Transfusions. British Journal of Haematology, 2003 122, 1 EU Commission Directives 2002/98/EC, 2004/33/EC, 2005/61/EC and 2005/62/EC (Blood

Safety and Quality Regulations) Norfolk D. 2007 “Handbook of Transfusion Medicine” 5th Ed. UK Blood Services London

TSO

The Blood Safety and Quality Regulations. Statutory Instrument 2005 No. 50 and addition amendments.

13 Appendices

Appendix A Blood Transfusion Chart Appendix B1 NHSBT Component Label Appendix B2 NHSBT Irradiation Indicator Label Appendix C1 Blood Compatibility Label Appendix C2 Electronic Blood Compatibility Label Appendix D Requesting Components in an Urgent Situation Appendix E Investigations of Moderate or Severe Acute Transfusion Reactions Appendix F Guidelines – Jehovah’s Witnesses & Blood Transfusion Appendix G Blood Transfusion Crossmatch Request Form Appendix H Blood Collection Slip Appendix I Financial and Resourcing Impact Assessment on Policy Implementation Appendix J Equality Impact Assessment (EIA) Screening Tool

http://www.transfusionguidelines.org.uk/transfusion-handbook


Appendix A


Appendix B1

NHSBT Component Label


RadTag®

RTG-S (GAMMA)

IRRADIATION INDICATOR

If central dot white, not irradiated If central dot blue, irradiated

Lot No. 9999 label Expiry: Jan 0000

RadTag®

RTG-S (GAMMA)

IRRADIATION INDICATOR

If central dot white, not irradiated If central dot blue, irradiated

Lot No. 9999 label Expiry: Jan 0000

Irradiated (Blue Dot)

NOT Irradiated (White Dot)

IRRADIATION INDICATOR LABEL

Appendix B2

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwj_vtvCjLrcAhUtzoUKHSFSDzQQjRx6BAgBEAU&url=http://ganedata.co.uk/blog/barcoding-solutions-understanding-barcodes/&psig=AOvVaw1q-gh0uDSNXuFtLXFCSTGf&ust=1532602808263689

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwj_vtvCjLrcAhUtzoUKHSFSDzQQjRx6BAgBEAU&url=http://ganedata.co.uk/blog/barcoding-solutions-understanding-barcodes/&psig=AOvVaw1q-gh0uDSNXuFtLXFCSTGf&ust=1532602808263689


IMPORTANT It is a legal requirement to

complete the tear off section overleaf and return it to the Blood Transfusion

Laboratory

Before Transfusion

Carry out these checks

• Ask the patient to state their name and date of birth.

• Check these details and the patients hospital number match the wristband and this label attached to the unit.

• This information must match the patients wristband No wristband No Transfusion

• Check the unit numbers is the same on the unit and this label.

• If any details do not match, contact the Blood Transfusion Laboratory

Do Not Transfuse

• If a transfusion reaction is suspected

• STOP the transfusion

• Seek medical advice

Isle of Wight NHS Primary Care Trust St Mary’s Hospital

BLOOD SAFETY & QUALITY

REGULATIONS 2005

For Laboratory use only Fate of unit entered on Laboratory computer

Incident form completed for this unit

IT IS A LEGAL REQUIREMENT TO

CONFIRM THE FATE OF THIS UNIT STOP! Before transfusion read

the information on the reverse

Unit No. Group Product Surname Forenames IW Hosp No DOB Ward Reserved until 9am Patients Group



S U I T A B L E

F O R

P A T I E N T

Isle

of W

ight N

HS

Prim

ary

Ca

re T

rust

St M

ary

’s H

osp

ita

l

Attach this peal off label to the Blood Transfusion Chart

I confirm that the above unit was:

Transfused (all or part) to the above named patient

Returned to the laboratory out of temperature control

Disposed as pack damaged

Print Name …………………………………………………. Signature ……………………………………………………. Date ………………………… Time …………………………

Blood Compatibility Label Appendix C1

THIS LABEL IS ATTACHED TO THE BLOOD OR BLOOD COMPONENT PACK

This tear off portion is to be fully completed and returned to the Blood Transfusion Laboratory as soon as possible

This “Peel Off” Sticker is to be affixed to the Blood Transfusion Chart


Appendix C2

Electronic Blood Compatibility Label

THIS LABEL IS ATTACHED TO THE BLOOD OR BLOOD COMPONENT PACK

2D Barcode

Label

This “Peel Off” Sticker is to be affixed to the Blood Transfusion

Chart


Appendix D Requesting Components in an Urgent Situation

Action Plan The Medical Officer should assess the degree of urgency and decide the type and

quantity of components required or if the Major Haemorrhage Protocol should be invoked. (Refer to Protocol for the Management of Major Haemorrhage and / or Trauma in Adults and Children for further guidance).

Request components by direct communication with the Blood Transfusion Laboratory (Ext. 4800) or Biomedical Scientist (BMS) for Transfusion via bleep indicating:

o Reason for transfusion o Patients Forename, Surname, Date of Birth & IW Number (or Unknown “male

/ female” and “U” or “E” number as appropriate) o Type and quantity of components required o Urgency of request o Location of the patient

If a G&S is held by the Blood Transfusion Laboratory then a telephone request can be made by a Medical Officer or other authorised Health Care Professional.

For ALL telephoned requests, the Blood Transfusion Laboratory staff will provide an “order number” to confirm the request. The Medical Officer or other authorised Health Care Professional MUST write this number in the patient’s medical records alongside the reason for the transfusion.

Any blood samples MUST be accurately and legibly labelled in accordance with any

samples for G&S / cross matching that are incorrect, incomplete or contain errors in labelling cannot be accepted and will be discarded

Samples should be sent to the Laboratory using Portering services. The Porters MUST be contacted by the requesting ward / clinical area, indicating degree of urgency of the request.

Blood required within:

a. 0 -15 minutes Extreme Emergency – Use of Emergency O RhD Negative Red cells (maximum four units normally available in the Blood Issue Fridge.

b. 15-30 minutes * - Issue of ABO RhD “Group Specific” blood from receipt of an appropriately labelled sample in the Blood Transfusion Laboratory.

c. 40+ minutes * - Issue of crossmatch compatible blood from receipt of an appropriately labelled sample in the Blood Transfusion Laboratory.

d. If a fully tested G&S sample is held in the Blood Transfusion Laboratory, cross matched blood can be made available in fifteen minutes unless the patient has known antibodies then cross matched blood will be made available as soon as possible.

e. A second sample will be requested by Transfusion Laboratory staff to confirm

the ABO group of any patient requiring blood components who has a current sample in the laboratory but has no historical group recorded on the LIMS


Appendix F


BLOOD TRANSFUSION CROSSMATCH REQUEST Lab No

DATE AND TIME OF COLLECTION

SURNAME IW. No.

SAMPLE COLLECTED BY: FORENAME

MALE FEMALE

CROSSMATCH DETAILS: NO OF UNITS REQUIRED ………………………………………………………………………………. DATE AND TIME REQUIRED …………………………………………………………………………… TO BE GIVEN / TO STAND BY

ADRESS/POSTCODE DATE OF BIRTH

NHS Private Temp Cat II Res

SPECIAL REQUIREMENTS CMV Neg Irradiated Other (Please State) ……………………………………………………………………………………….

CONS/GP

LOCATION

COPY TO

ESSENTIAL INFORMATION PATIENTS BLOOD GROUP ANTIBODIES DETECTED YES NO PREVIOUS TRANSFUSIONS YES NO

CLINICAL DATA INCLUDING DRUP THERAPY PHONE BLOOD BANK FOR URGENT (SAME DAY) REQUESTS LMP: EDD:

REQUESTIONG DOCTOR (print) Singnatue: Date:

ISLE OF WIGHT HEALTHCARE NHS TRUST ISLE OF WIGHT PO30 5TG TEL (01983) 524081 FAX (01983) 825437

Appendix G Blood Transfusion Crossmatch Request Form


Appendix H Blood Collection Slip

BLOOD COMPONENTS TO BE COLLECTED (No of Units)

Red cells FFP Platelets Cryoprecipitate Other

Patient Forename Surname IW Number

Date of Birth _ _/_ _/_ _ Requested by: Name Time __ __ Date _ _/_ _/_ _ Ward Emergency/Routine Blood Transfusion Laboratory: Blood Collection Slip 21/10/908


Appendix I Financial and Resourcing Impact Assessment on Policy Implementation

NB this form must be completed where the introduction of this policy will have either a positive or negative impact on resources. Therefore this form should not be completed where the resources are already deployed and the introduction of this policy will have no further resourcing impact.

Document title

Policy For The Transfusion Of Blood And Blood Components

Totals WTE Recurring £

Non-Recurring £

Manpower Costs 0 0 0

Training Staff 0 0 0

Equipment & Provision of resources 0 0 0

Summary of Impact: The policy of the Organisation regarding the requesting, sampling, prescribing, transport, storage, administration, care of patient receiving and treatment & reporting of an adverse event for blood and blood components based on National and European Regulations and Guidelines Risk Management Issues: This policy is document is designed to support effective risk management across the Trust by decreasing the risk of patient exposure to errors and is an important element of the risk management of patients in this Organisation Benefits / Savings to the organisation: Effective risk management will support the Trust to deliver its service efficiently, effectively with due regard to the financial envelope and quality agenda. Failure to have this policy in place and implemented would mean that patients’ lives potentially will be put at risk. Ultimately Chief Executives are at risk of being prosecuted for non-compliance of the Blood Safety and Quality Regulations (2005), and the Organisation’s would be in danger of losing their licence for being a Blood Establishment Equality Impact Assessment Has this been appropriately carried out? YES/NO Are there any reported equality issues? YES/NO If “YES” please specify: Use additional sheets if necessary. Please include all associated costs where an impact on implementing this policy has been considered. A checklist is included for guidance but is not comprehensive so please ensure you have thought through the impact on staffing, training and equipment carefully and that ALL aspects are covered.


Capital implications £5,000 with life expectancy of more than one year.

Funding /costs checked & agreed by finance:

Signature & date of financial accountant:

Funding / costs have been agreed and are in place:

Signature of appropriate Executive or Associate Director:

Manpower WTE Recurring £ Non-Recurring £

Operational running costs 0 0 0

Totals: 0 0 0

Staff Training Impact Recurring £ Non-Recurring £

Totals: 0 0

Equipment and Provision of Resources Recurring £ * Non-Recurring £ *

Accommodation / facilities needed 0 0

Building alterations (extensions/new) 0 0

IT Hardware / software / licences 0 0

Medical equipment 0 0

Stationery / publicity 0 0

Travel costs 0 0

Utilities e.g. telephones 0 0

Process change 0 0

Rolling replacement of equipment 0 0

Equipment maintenance 0 0

Marketing – booklets/posters/handouts, etc. 0 0

Totals:


Appendix J

Equality Impact Assessment (EIA) Screening Tool

1. To be completed and attached to all procedural/policy documents created within

individual services.

2. Does the document have, or have the potential to deliver differential outcomes or affect in an adverse way any of the groups listed below? If no confirm underneath in relevant section the data and/or research which provides evidence e.g. JSNA, Workforce Profile, Quality Improvement Framework, Commissioning Intentions, etc. If yes please detail underneath in relevant section and provide priority rating and determine if full EIA is required.

Gender

Positive Impact Negative Impact

Reasons

Men N/A N/A

Women N/A N/A

Race Asian or Asian British People

N/A N/A

Document Title: Policy For The Transfusion Of Blood And Blood Components

Purpose of document

The transfusion of blood and blood products is an important, often lifesaving, part of the treatment of many patients. It is also a procedure that has an element of risk, with errors potentially leading to the death of or long term damage to a patient who receives the wrong blood. This forms the policy of the Organisation regarding the requesting, sampling, prescribing, transport, storage, administration, care of patient receiving and treatment & reporting of an adverse event for blood and blood components based on National and European Regulations and Guidelines

Target Audience

This policy aims to inform and guide healthcare professionals who are involved in the transfusion process of safe transfusion practice and is the shared responsibility of all staff involved in the various stages of the Transfusion Process

Person or Committee undertaken the Equality Impact Assessment

Hospital Transfusion Team / Committee


Black or Black British People

N/A N/A

Chinese people

N/A N/A

People of Mixed Race

N/A N/A

White people (including Irish people)

N/A N/A

People with Physical Disabilities, Learning Disabilities or Mental Health Issues

N/A N/A

Sexual Orientation

Transgender N/A N/A

Lesbian, Gay men and bisexual

N/A N/A

Age

Children

N/A N/A

Older People (60+)

N/A N/A

Younger People (17 to 25 yrs.)

N/A N/A

Faith Group YES N/A

Provides guidance on

treatment of patients who

refuse transfusions / blood

components on the grounds

of religion. See Appendix E -

Guidelines – Jehovah’s

Witnesses & Blood

Transfusion

Pregnancy & Maternity

N/A N/A

Equal Opportunities and/or improved relations

N/A N/A

Notes: Faith groups cover a wide range of groupings, the most common of which are Buddhist, Christian, Hindus, Jews, Muslims and Sikhs. Consider faith categories individually and collectively when considering positive and negative impacts.


The categories used in the race section refer to those used in the 2001 Census. Consideration should be given to the specific communities within the broad categories such as Bangladeshi people and the needs of other communities that do not appear as separate categories in the Census, for example, Polish. 3. Level of Impact If you have indicated that there is a negative impact, is that impact: YES NO Legal (it is not discriminatory under anti-discriminatory law) N/A N/A

Intended N/A N/A If the negative impact is possibly discriminatory and not intended and/or of high impact then please complete a thorough assessment after completing the rest of this form. 3.1 Could you minimise or remove any negative impact that is of low significance? Explain how below: 3.2 Could you improve the strategy, function or policy positive impact? Explain how below: 3.3 If there is no evidence that this strategy, function or policy promotes equality of opportunity or improves relations – could it be adapted so it does? How? If not why not? Scheduled for Full Impact Assessment Date: Name of persons/group completing the full assessment.

Andy Thompson

Date Initial Screening completed 02/11/2018