Better Blood Transfusion

Module 1

SAFE TRANSFUSION PRACTICE

Self-Directed Learning Pack

Better Blood Transfusion Scottish National Blood Transfusion Service Version 2010

Disclaimer Whilst the information in this pack is believed to reflect current best clinical practice, neither authors nor publisher can accept any legal responsibility for any errors or omissions. Revision date: 2012 Better Blood Transfusion, Scottish National Blood Transfusion Service, 2004 Better Blood Transfusion Scottish National Blood Transfusion Service Ellens Glen Road Edinburgh EH17 7QT Tel: 0131 536 5962 Fax: 0131 536 5961

Contents
Introduction Better Blood Transfusion Better Blood Transfusion: A continuing education programme Module 1: Safe Transfusion Practice Finding a learning supervisor Planning your study 1. 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2. 2.1 2.2 2.3 2.4 2.5 2.6 3. 3.1 3.2 3.3 3.4 4. 4.1 4.2 4.3 4.4 5. 5.1 5.2 5.3 6. 6.1 6.2 6.3 7. 7.1 7.2 7.3 7.4 7.5 The Transfusion Process Steps in the transfusion process Haemovigilance in the Uk and republic of Ireland The UK Serious Hazards of Transfusion Scheme SHOT Report categories Incorrect blood component transfused Immune reactions and infections Near-miss scheme Conclusions and recommendations from the SHOT Report Professional accountability Blood Group Serology Blood group systems The ABO blood groups Transfusion of fresh frozen plasma, cryoprecipitate and platelets The RhD Blood Group Compatibility testing Later provision of blood Ordering Blood Gaining Consent Completing the blood request form Taking the pre-transfusion blood sample Communicating with the hospital transfusion laboratory Collecting, Delivering and Storing Blood Components Documentation Collecting or delivering blood components Storing and transporting blood components Unused blood components Checking and Administering Blood Components Checking the component and the patient before transfusion Administering blood components Using infusion devices Monitoring the Transfused Patient Observing the patient Documenting the transfusion Initial management of an adverse event Paediatric Transfusion Blood group serology Ordering blood Collecting, delivering and storing blood components Administering blood components Monitoring the transfused patient 1 1 2 2 4 5 9 10 12 12 14 16 17 18 19 20 222 23 23 25 26 27 27 29 30 31 33 35 38 39 39 40 43 45 46 51 53 56 57 59 60 64 65 65 67 68 70

8. 8.1 8.2 8.3

Action Plan Reviewing your progress Making an Action Plan Implementing your Action Plan

71 72 72 75 78 79 81 82 83

Activity Answers Glossary of Terms References Resources Recommended Reading

Introduction
Better Blood Transfusion
In 1999, the Department of Health published a circular, Better Blood Transfusion (HSC, 1998; MEL, 1999 (9). The circular aimed to improve transfusion practice by mandating all hospitals where blood and blood products were transfused to have an adequately resourced, multidisciplinary Hospital Transfusion Committee (HTC) in place. The HTC is seen as an integral part of clinical governance and should, as a minimum: Promote best transfusion practice through the development of local protocols Lead multi-professional audit of the use of blood components Maintain a database that allows feedback on performance to all hospital staff involved in blood transfusion Promote the education and training of all clinical and support staff involved in blood transfusion. Further guidance was published in 2002/03, Better Blood Transfusion (HSC, 2002/009) (NHSHDL (2003) 19), WHC (2002) 137; HSS (MD) 6/03. In September 2006, NHS Quality Improvement Scotland developed Standards for Transfusion. The clinical performance of each Scottish hospital will be assessed against these standards, and they will be required to provide evidence that all staff involved in blood transfusion have received training, Also issued in 2006 by the National Patient Safety Agency (NPSA) was the Safer Practice Notice 14; Right Patient, Right Blood, which relates to England and Wales. The Safer practice notice instructs all NHS Trusts and the independent sector to formally examine their blood transfusion procedures and appraise the feasibility of the use of the following: photo ID cards for regular patients receiving blood electronic tracking systems for patients and blood labelling system for matching samples and blood to patient. Hospitals must also ensure that the compatibility from is not used as part of the final patient identity check, and have drawn up a plan that describes how all staff involved in blood transfusion will be trained and have their competency assessed and this is to be revisited every three years. This covers doctors, nurses, porters, phlebotomists, operating department practitioners and health care assistants.

The Safe and Effective Transfusion study undertaken by the Effective Use of Blood (EUB) Group of the Scottish National Blood Transfusion Service has, however, demonstrated that up to 75% of registered general nurses

and 22% of doctors have never received any continuing education in blood transfusion since completing their initial training (Gray et al, 2003).

Better Blood Transfusion: A continuing education programme

Better Blood Transfusion is a self-directed learning programme developed by the Scottish National Blood Transfusion Service. The Better Blood Transfusion continuing education programme has been designed to assist practitioners involved in the transfusion process to provide consistently high standards of care. The programme has been developed at three levels, with some aspects particularly designed for those with limited access to conventional training courses.

Module 1: Safe Transfusion Practice is the first module in the series. It is aimed at all staff groups involved in the administration of blood
components, including medical and nursing staff, operating department practitioners, clinical support workers and porters. This self-directed learning pack, Safe Transfusion Practice, complements the face-to-face teaching materials. Module 2: Blood Component Use covers the constituents of blood components and summarises the indications for use, the therapeutic risks and benefits and the management of adverse events. The module has been designed for clinicians, nurses and operating department practitioners who regularly use blood components in their day-to-day practice. Module 2 can also be used to prepare practitioners involved in the delivery of Module 1: Safe Transfusion Practice training to health care workers. Module 3: Appropriate Transfusion Practice deals with issues such as the use of transfusion guidelines and triggers, informed consent and alternatives to allogeneic transfusion. This module has been designed for doctors and nurses regularly involved in the management of patients requiring transfusion support. As demand for the programme has increased and to address the difficulty some healthcare workers have in accessing educational materials, these modules have been available on the World Wide Web as an e-learning programme. The e-learning site can be accessed at: www.learnbloodtransfusion.org.uk

Module1: Safe Transfusion Practice

Module1: Safe Transfusion Practice, is the foundation module in the Better Blood Transfusion continuing education programme. Staff who have worked through this unit and apply the information acquired can be confident that they are providing patients with consistent and safe care throughout the transfusion process.

Subject specialists have specially written this self-directed learning pack for the Better Blood Transfusion programme. It is different from a conventional textbook because it is not simply concerned with providing information and increasing your theoretical knowledge, although this is a fundamental aim of the programme. More importantly, it is designed to help you apply your knowledge more effectively in your everyday work so that you provide consistently high standards of care to your patients throughout the transfusion process. The Module1 pack contains the following sections covering the ordering and administration of blood components and the management of the transfused patient. Section 1: The Transfusion Process introduces you to the Serious Hazards of Transfusion Scheme and outlines the different steps and the most common errors in the transfusion process. It also includes a brief discussion on professional accountability. Section 2: Blood Group Serology explains the importance of ABO and RhD blood group compatibility in blood transfusion practice. Section 3: Ordering Blood focuses on the procedures for requesting blood components and taking blood samples for pre-transfusion testing. Section 4: Collecting, Delivering and Storing Blood Components focuses on procedures for collecting blood components and storing them safely until they are transfused. Section 5: Checking and Administering Blood Components emphasises the importance of the final patient identification check at the bedside before transfusion and the selection and correct use of blood administration sets and infusion devices. Section 6: Monitoring the Transfused Patient focuses on the management of the transfused patient and the initial response to a transfusion reaction. Section 7: Paediatric Transfusion focuses on the special features of paediatric transfusion, including the identification and monitoring of paediatric patients. Section 8: The Action Plan draws together your work on the pack by asking you to assess your own progress in relation to the anticipated learning outcomes of the pack. This will help you develop an action plan in relation to any changes that you think are needed to improve the quality and safety of transfusion practice in your own clinical area. Each section begins with a list of learning outcomes that identify what you should be able to do when you have completed that section and concludes with a list of Key Points that summarise the main issues that have been

covered. You may find it helpful to add your own key points in the light of working through the activities in the section. At the end of the pack you will find references and suggestions for further reading that should help you to pursue areas of particular interest.

Activities
As you work through each section, you will be asked to complete a number of activities. These are designed to help you to explore the concepts and issues raised in the text and apply them to your own practice. The two activities in this introductory section are designed to help you prepare for your studies by: Identifying a personal learning supervisor or mentor for your work on this unit Assessing your current knowledge, skills and experience in relation to each section. Many of the activities ask you to review current approaches and procedures in your own clinical area, try out new ideas and identify ways of improving specific aspects of your work. They may suggest that you consult with your clinical manager and other colleagues, look at records or search for information, as well as plan and carry out particular tasks. These activities may take some time to complete, but it is important to do them thoroughly since the purpose is to help you to do your job more effectively and to identify any improvements in transfusion practice needed in your own clinical setting. You will find answers to Activities 7 and 21 on p. 78. There are no right or wrong answers to the other activities because they are not designed to test your knowledge. Since they focus directly on your own work, your responses will generally depend on local conditions and circumstances. Keep a special file or notebook for your notes. If you need help in carrying out any of the activities, you will find it helpful to discuss them with your learning supervisor.

Finding a learning supervisor

Before you start work on this pack, you will need a learning supervisor who can support you in your study and help you to apply what you are learning to your own practice. Your local facilitator or transfusion practitioner/haemovigilance officer may be able to support you while you are working through the Module1: Safe Transfusion Practice programme. They will have access to resource materials that you may find useful when undertaking your learning activities. A local facilitator has been identified within your hospital to co-ordinate the Better Blood Transfusion continuing education programme. If you have enrolled on the Module1: Safe Transfusion Practice programme, you will already have made contact with your facilitator. They will help you identify a personal learning supervisor

who can support you in your clinical area while you are working through the pack.

ACTIVITY 1
Find out who your representative is on your local Hospital Transfusion Committee. Does the HTC publish a regular update of their activities? If not, consider contacting your local HTC representative for more information.

Planning your study

The pack should take up to 20 hours to complete. The study time includes the completion of the activities, which should be useful in improving transfusion practice in your own clinical area. The majority of the activities can be undertaken during the course of your normal working day. There may be some material that is new to you so take as much time as you need to work through each section. You may like to make a note of any parts that you find difficult and return to them at a later time. Where sections contain material that is already familiar to you read them through carefully as a means of revision. Talk to your learning supervisor if you want to discuss any issues in more depth or are having problems in completing any of the activities. You might also want to discuss how to plan your study and to seek assistance in negotiating study time with your line manager. Your learning supervisor should also be able to help you find any reading materials you need that are unavailable in your own clinical area. Remember that your work on this pack will directly benefit your practice so its important to ask for any help you need. If there are others in your hospital who are also working through the pack, you may find it helpful to approach the local facilitator about setting up an informal study group to discuss the issues raised and share your responses to the activities.

Identifying your learning priorities

Before moving on to Section 1, complete Activity 2, which asks you to look at the anticipated learning outcomes for each section. These are designed to provide a framework for you to identify areas on which you particularly need to focus and to assess your own progress.

ACTIVITY 2
Look at the list of anticipated learning outcomes for Sections 17 on pp. 7-8. Use them to help you assess your current knowledge, skills and experience in relation to transfusion practice.

For each learning outcome consider where you think you are now. Using a scale of 1 to 4 (where 1 represents a high level of knowledge, skills and experience and 4 equals none at all), tick the box on the scale that most closely corresponds to your current knowledge, skills and experience related to each outcome. Make a note of any sections that you consider being a particularly high priority for you. This should help you to plan your study time and identify any areas where you would particularly like help from e.g., your local transfusion practitioner/haemovigilance officer, supervisor or clinical manager etc.

Learning Outcomes Section 1 - The Transfusion Process

1 Identify the points at which you are involved in the transfusion process 2 Identify the most common errors in the transfusion process 3 Outline your professional accountability in relation to the transfusion process

Section 2 - Blood Group Serology

1 Understand the importance of blood group systems in the provision of compatible blood 2 Be aware of the options available to the hospital transfusion laboratory for the supply of blood to your patients 3 Communicate this information to patients, relatives and less experienced colleagues

Section 3 - Ordering Blood

1 Inform patients of the expected benefits, risks and outcomes of transfusion 2 Ensure that the blood request form is completed clearly and accurately 3 Correctly label the blood sample tube 4 Communicate effectively with the hospital transfusion laboratory to ensure that the right patient receives the right blood at the right time

Section 4 - Collecting, Delivering & Storing Blood

1 Follow the correct procedures for checking the patients identification details and the traceability label attached to the blood component to ensure that the correct pack is withdrawn from its storage location 2 Document the collection and delivery of blood components and their removal from the ward or theatre refrigerator

3 State the correct temperature ranges for the storage of blood components 4 Ensure that blood components are kept in the correct storage conditions during transportation and in the clinical area before administration to the patient 5 Follow the correct local procedures for returning unused blood components to the hospital transfusion laboratory

Section 5 - Checking and Administering Blood

1 Explain the importance of meticulous checking of patient identification details, documentation and the blood component at each stage of the transfusion process 2 Correctly undertake the formal patient identity check at the bedside before the transfusion of every unit of blood component in order to prevent the administration of an incompatible blood component to a patient 3 Select and correctly use the appropriate equipment when administering blood components 4 Select and correctly use an appropriate infusion device, when indicated

Section 6 - Monitoring the Transfused Patient

1 Monitor patients appropriately before, during and on completion of a blood transfusion 2 Correctly document each transfusion episode 3 Recognise, and take appropriate initial action in response to a possible transfusion reaction

Section 7 - Paediatric Transfusion

1 Identify the specific requirements of paediatric patients requiring transfusion. 2 State the particular precautions that need to be taken in the identification and monitoring of paediatric patients, particularly neonates and infants.

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The Transfusion Process
Blood transfusion is a complex, multi-step process that crosses several professional and management boundaries and may involve many individuals. There is potential for error at each stage of the process. The findings of the Serious Hazards of Transfusion (SHOT) Scheme have shown that, in each successive year since its launch in 1996, human error has contributed to morbidity and mortality among a significant number of patients receiving blood transfusions. The purpose of this section is to outline the SHOT Scheme and its findings in order to highlight the points in the transfusion process where particular care is needed to ensure safe and effective transfusion practice. Subsequent sections will focus on specific steps in the process.

Learning outcomes
When you have completed this section, you should be able to: 1 Identify the points at which you are involved in the transfusion process. 2 Identify the most common errors in the transfusion process. 3 Outline your professional accountability in relation to the transfusion process.

1.1

Steps in the transfusion process

Providing a safe blood transfusion is a complex process that involves a number of different steps, staff groups and departments, as shown in Figure 1.1 below and Figure 1.2 . There is considerable potential for human and technical error at each stage of this process. All staff involved in blood transfusion are required to undertake regular training and be assessed as competent (in accordance with NPSA SPN 14 (2006), or, for Scotland, with NHS QIS Clinical Standards for Blood Transfusion (2006) for the specific tasks they are involved with. Where activities fall under the remit of the BSQR (SI2005 No.50 as amended), for example, the collection and distribution of blood components the regulations state that no staff member should participate in this task unless they have evidence of regular competency assessments.
Figure 1.1 The transfusion process: requesting blood components

Assess patients clinical need for transfusion Doctor / Nurse Discuss the need for transfusion with patient Record indication for transfusion in the patients records

Doctor

Complete blood request form

Doctor / Nurse / Operating Department Practitioner (ODP) / Clinical Support Worker (CSW)/ or other healthcare practitioner

Take blood sample for pretransfusion testing

Doctor / Nurse / Phlebotomist/ ODP / CSW/ or other healthcare practitioner

Transport blood sample + request form to hospital transfusion laboratory

Porter / Doctor / Nurse / Phlebotomist / ODP / CSW/ or other healthcare practitioner

Perform pre-transfusion screening and compatibility tests Select compatible units Generate compatibility form and blood bag labels Release components to clinical unit Biomedical Scientist (BMS)/ Laboratory technician

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ACTIVITY 3
Look at Figures 1.1 and 1.2 and identify the steps in the transfusion process in which you are involved. How confident are you that you know and undertake exactly the correct procedures at each of these stages to ensure that the right blood reaches the right patient at the right time? As you work through the pack, you will begin to identify potential weak points in the transfusion process in your hospital and clinical area. Your work on the activities should help you to suggest ways, in which they can be strengthened, to the benefit of both patients and practitioners.
Figure 1.2 The transfusion process: collection, storage and administration of blood components
Doctor

Prescribe blood components

Collect/deliver blood components from hospital transfusion laboratory / satellite fridge

Porter / Nurse / Doctor / CSW / ODP/ or other healthcare practitioner Nurse / Doctor / ODP/ or other healthcare practitioner

Receive blood components in clinical area

Store blood components in authorised blood refrigerator Perform pre-administration checks before commencing the transfusion Undertake and record baseline observations Perform the final patient identity check at the bedside before administering the transfusion Monitor patients temperature and pulse 15 minutes after transfusion has commenced Observe patient at regular intervals Respond to any adverse event

Nurse / Doctor / ODP / CSW Or other healthcare practitioner

Nurse/Doctor/ODP +/ CSW/ or other healthcare practitioner

Reassess the need for further transfusion Record completed transfusion Record post-transfusion laboratory results and clinical outcome in patient records

Doctor

Doctor/Nurse

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1.2

Haemovigilance in the UK and Republic of Ireland

Around 3 million units of red cells are transfused every year in the UK. Blood transfusion in this country is a very safe process which, when used appropriately, saves lives and improves the quality of life in a large range of clinical conditions. Nevertheless, as with any other clinical intervention, there are a number of risks associated with this therapy. Many health care professionals and members of the general public consider the transmission of infectious disease to be the greatest potential threat from the transfusion of blood components. However, annual reports from the Serious Hazards of Transfusion Scheme have shown that human error during the transfusion process, particularly in relation to patient identification, presents by far the greatest risk to the patient. Medical and nursing staff, operating department practitioners (ODPs), clinical support workers (CSWs) and porters all have a vital role to play in ensuring that the transfusion process is carried out safely and professionally, with particular emphasis on the correct identification of the patient and component at all times. Republic of Ireland users, can access the latest National Haemovigilance Office (NHO) annual report at http://www.giveblood.ie/Clinical_Services/Haemovigilance/publications

1.3

The UK Serious Hazards of Transfusion Scheme

The potential risks associated with transfusion have been highlighted by the Serious Hazards of Transfusion (SHOT) Scheme, which was launched in November 1996. It is a voluntary, anonymised reporting scheme covering both NHS and private hospitals in the United Kingdom and Ireland. Its aim is to collect data on the serious sequelae of the transfusion of blood components in order to: Educate users in transfusion hazards and their prevention Inform policy within transfusion services Improve standards of hospital transfusion practice Aid the production of clinical guidelines on the use of blood components. Since SHOT commenced, the number of submitted reports has continued to rise as awareness of, and confidence in the reporting scheme has increased amongst its users. Participation in SHOT has ranged from 22% to 92% of UK hospitals. Reports of serious adverse reactions to blood components (plasma, cryoprecipitate, platelets, and granulocytes) are received from haematologists (and occasionally other staff members) in hospitals and

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transfusion centres. All established serious adverse events are followed up with a detailed questionnaire. Suspected cases of transfusion-transmitted infection are reported by haematologists through supplying Blood Centres to the Public Health Laboratory Communicable Disease Surveillance Centre. Local Blood Centre involvement is essential to ensure the withdrawal of other potentially infected components. Data are stored in a password-protected database in a secure location. Once all the information has been gathered about the incident and entered onto the database without patient, staff or hospital identifiers, all reporting forms and other paper records that contain any identifiers are shredded. The questionnaires (which have any possible identifiers removed) are kept in a secure container until data analysis for the report is complete. They are then destroyed. SHOT does not provide details of individual cases or any form of summarised data to any outside person or organisation, other than that provided in its Annual Report. The SHOT group has advised that their recommendations should be used locally to support risk management, clinical governance and education. The authors also recommended that reporting of transfusion related adverse events should be the norm and that individuals who are familiar with good practice guidelines for transfusion should undertake full investigation of reported incidents. It was also advocated that the SHOT findings should form part of mandatory training for all staff involved in the transfusion process (Stainsby et al., 2003). In addition to the voluntary SHOT reporting scheme, since 2005, the transfusion of blood components has been covered by UK legislation under the Blood Safety and Quality Regulations (2005). The regulations apply particularly to the laboratory aspects of the transfusion process but also involve clinical areas because they cover storage, distribution and traceability of all components. The regulation requires unmistakable traceability of every blood component from donor to patient or final fate if not transfused. The person giving the transfusion is responsible for confirming to the laboratory, by whatever system is in place, that a component has actually been given to a specific individual (Full traceability). Issue from the HTL is no longer sufficient proof that the individual has received the component. These records must be kept for 30 years. If a component is discarded for any reason this information must also be confirmed to the laboratory. Laboratories are required to have a quality management system and have a full audit trail of the storage conditions for all components. It is therefore essential that accurate documentation of time of removal (and return if applicable) of components is maintained at all stages

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It is also now a legal requirement to report all serious adverse reactions and event to the identified competent authority, check with local protocols for method of reporting

1.4

SHOT Report categories

The SHOT Scheme aims to capture data on the following major complications of transfusion. 1 Incorrect Blood Component Transfused (IBCT): The transfusion of a blood component that was either not intended for that patient or was, in some way, unsuitable for them: e.g., the patient is in a susceptible group but was not transfused with CMVnegative blood. Almost without exception, IBCT incidents are due to human error. 2 Acute Transfusion Reaction (ATR): A serious acute reaction (allergic, haemolytic, etc.) occurring within 24 hours of transfusion. This category generally does not include febrile transfusion reactions, as these are common and generally mild. 3 Anti-D Related Events: Events relating to the administration of anti-D immunoglobulin. Please note that this category now includes events relating to the administration of anti-D following transfusion of RhD-mismatched platelets. 4 Handling and Storage Errors (HSE): Transfusion of a correct component to an intended patient, when handling or storage errors may have rendered the component less safe for transfusion 5 Haemolytic Transfusion Reactions (Acute and Delayed): Acute HTRs are defined as fever and other symptoms / signs of haemolysis within 24 hours of transfusion; confirmed by one or more of the following in: a fall of Hb, rise in LDH, positive DAT and positive crossmatch. Delayed HTRs are defined as fever and other symptoms / signs of haemolysis more than 24 hours after transfusion; confirmed by one or more of: a fall in Hb or failure of increment, rise in bilirubin, positive DAT and positive crossmatch not detectable pretransfusion. Simple serological reactions (development of antibody without positive DAT or development of haemolysis) are excluded. Please report these in the Alloimmunisation category. 6 Inappropriate and Unnecessary Transfusion (I&U): These are cases in which the intended transfusion is carried out, and the component itself is suitable for transfusion and for the patient, but where the decision making is faulty. There are also cases where a

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transfusion of blood or a blood component was clinically indicated but was not undertaken. 7 Transfusion-Related Acute Lung Injury (TRALI): An immunemediated reaction in the lungs, usually due to antibodies from the donor occurring during, or within hours of, a transfusion. The patient becomes hypoxic and often requires ventilation. 8 Transfusion-Transmitted Infection (TTI): Any infection or septic reaction occurring due to the presence of infectious organisms (viral, bacterial, fungal, protozoal), or toxins from these organisms, in the transfused component. Transfusion-transmitted infections include: Human immunodeficiency virus (HIV) Hepatitis B Hepatitis C HTLV-1 Syphilis Malaria Chagas disease. 9 Post-Transfusion Purpura (PTP): The development of severe thrombocytopenia within a few days of transfusion. PTP is an immune reaction to platelets in the transfused component and is often associated with severe bleeding problems. 10 Autologous Transfusion: Events and reactions in relation to the use of intraoperative and postoperative cell salvage. 11 Transfusion-Associated Circulatory Overload (TACO): Any four of the following occurring within six hours of transfusion: Acute respiratory distress. Tachycardia Increased blood pressure. Acute or worsening pulmonary oedema. Evidence of positive fluid balance. 12 Transfusion-Associated Graft-versus-Host Disease (TAGvHD): Characterised by fever, rash, liver dysfunction, diarrhoea, pancytopenia and bone marrow hypoplasia occurring less than 30 days after transfusion. The condition is due to engraftment and clonal expansion of viable donor lymphocytes in a susceptible host. 13 Transfusion-Associated Dyspnoea (TAD): TAD is characterised by respiratory distress within 24 hours of transfusion that does not meet the criteria of TRALI, TACO, or allergic reaction. Respiratory distress should not be explained by the patient s underlying condition.

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In 2007 SHOT moved the Anti-D events into a separate category. The cumulative data has been adjusted accordingly. In 2007, SHOT also started collecting data related to Transfusionassociated circulatory overload (TACO). Figure 2 gives an overview of the cases reported between 1996 and 2008.
Figure 2 Overview of cumulative number of cases reviewed - SHOT 1996 - 2008 (n=5374)
28 18 13 7 1 236 329
HSE HTR Anti-D IBCT ATR

49 66

396
I&U

2355

TRALI TTI PTP Autologous

507

535

TACO TAGvHD

834

Unclassified TAD

1.5

Incorrect blood component transfused

You will see from Figure 2 that the largest number of serious adverse events reported to SHOT were in the category of Incorrect Blood Component Transfused. The majority of these incidents involved the administration of a unit of blood intended for another patient and many involved more than one error in the transfusion process. In the IBCT category a total of 5 patients suffered major morbidity definitely, probably or possibly related to the transfusion. The errors that resulted in the transfusion of an incorrect blood component included: The blood sample was drawn from the wrong patient Patient details were recorded incorrectly on the blood sample label or the blood request form The incorrect unit was collected from the blood refrigerator

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 The formal identity check at the patients bedside was omitted or performed incorrectly at the time of the administration of the blood component. Figure 3 shows a breakdown of the sites of error between 1996 and 2008. Figure 3 Distribution of Errors in IBCT Category SHOT Report (2008) (n=531)
47 5

193

100

17

Administration of wrong blood component Wrong blood in tube Special requirement not met - CMV/irrad Special requirement not met - other Laboratory errors Miscellaneous IBCT Inappropriate and Unnecessary Transfusion Handling and Storage Errors

91 76 2

A common feature of these cases is that the blood is checked away from the patients side against the compatibility form and that no wristband or other identity check was carried out. In some instances, more than one error occurred in the course of the transfusion episode. There have been cases in which two or more errors occurred and as many as seven errors have been reported in three cases. These errors involved porters, registered and unregistered nurses, doctors and operating department personnel No staff group of staff was immune Throughout the pack, we will use a number of SHOT case studies to highlight how failure to follow procedures can result in a patient receiving the wrong unit of blood, often with serious outcomes for the patient. The transfusion of an incorrect blood component is preventable. SHOT has summed up the correct outcome of the transfusion process in the following simple slogan:

1.6

Immune reactions and infections

Immune reactions
While the transfusion of the incorrect blood component is due to human

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error and is entirely preventable, immune reactions (ATR, DTR, PTP, TAGvHD, TRALI) are generally neither predictable nor preventable with our current state of knowledge. Since 1996, a significant number of patients in these groups died as a result of the reaction or experienced major morbidity.

Infections
Surveillance from 1995-2008, there were 67 confirmed transfusiontransmitted infections involving 62 recipients. Of these, 40 received bacterially contaminated blood components and 10 subsequently died.

Bacterial infections are generally due to the passage of bacteria from the donors skin into the pack, with subsequent growth within the stored pack. Occasionally, the donor is actually bacteraemic, but asymptomatic. Efforts to prevent bacterial contamination of packs include the implementation of donation packs, which divert the first few ml of the donation; this prevents any organisms entering the pack from the collection needle via the donation site and improvements in the cleansing of donors arms.

1.7

Near-miss scheme

In 199899, the SHOT scheme introduced a pilot scheme for near-miss. All UK hospitals have been eligible to participate in the scheme since 2000. Near-misses are defined as: 'Any error, which, if undetected, could result in the determination of a wrong blood group, or issue of an incorrect or inappropriate component, but which was recognised before transfusion occurred.' Near-miss reporting is a good indicator of any weak points in a process. A near-miss event can be described as an adverse event that occurs however, the system in place detects and corrects the event, so no harm is done. There are six categories of error: Sample errors Laboratory component selection, handling and storage errors Laboratory sample handling and / or testing errors Component issue, transportation, collection and administration errors Request errors Miscellaneous errors Since the near-miss scheme was introduced sampling errors have been the largest category reported. It is important however, to recognise that only about 50% of samples received by a hospital transfusion laboratory are from patients who have been previously tested in that laboratory. In addition, the error will only be detected if the patient named on the blood

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sample label and the patient who has actually been bled are of different blood groups. For this reason, then, we can assume that the actual number of errors is at least twice that detected.

1.8 Conclusions and main recommendations from the SHOT Reports

The following points provide a brief overview of the findings and main recommendations from SHOT: The majority of serious adverse events associated with transfusion were due to human error. Each of these could have been prevented if those involved in the transfusion process had adhered to appropriate standards of practice. Participation in SHOT must be active. Every hospital should have a procedure for ensuring that serious transfusion adverse events are fully investigated and reported to SHOT. An open learning and improvement culture must be developed in which the emphasis is on learning from errors and near misses in transfusion. Both SHOT and the Department of Health advise that hospitals involved in blood transfusion should establish and support a team approach to transfusion, involving a lead clinician in blood transfusion, a hospital transfusion practitioner/haemovigilance officer and a hospital laboratory manager. Training in blood transfusion should be implemented and competency testing developed for all hospital staff who contribute to the transfusion process. Hospital clinical governance committees should establish an appropriate action plan, based on the SHOT recommendations, aimed at improving the safety of administration of blood components within their organisation. Blood transfusion should be prescribed by practitioners that have been authorised by the hospital following appropriate training.

ACTIVITY 4
You should access the most recent copy of the summary of the SHOT Report at the website (see p. 82 for details). This should give you a clearer picture of the risks associated with transfusion, how they arise and how they might be prevented. Then read the British Committee for Standards in Haematology (BCSH) Guidelines on the Administration of Blood Components available at their website (see p.82). As you work through the pack, you will be asked to complete a number of activities that suggest you evaluate procedures in

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your own clinical area. Use the material in this pack and the BCSH Guidelines as a basis for this evaluation.

1.9

Professional accountability

Every health care practitioner is subject to the law, both as a member of society and as a professional. As a registered nurse or doctor, you are personally accountable for your professional practice. You are accountable to patients for the provision of safe and appropriate care during the transfusion process. You are also accountable to your functional employer (the hospital) for the provision of care appropriate to your level of knowledge and skills. Nurses and doctors must adhere to professional standards drawn up by their governing bodies: the Nursing and Midwifery Council (NMC) or the General Medical Council (GMC). As stated in the NMC Code of Professional conduct: standards for conduct performance and ethics (2008), nurses must: Act always in such a manner as to promote and safeguard the interests and well-being of patients Ensure that no action or omission on your part, or within your sphere of responsibility, is detrimental to the interests, condition or safety of patients Maintain and improve your professional knowledge and competence Acknowledge any limitations in your knowledge and competence and decline any duties or responsibilities unless able to perform them in a safe and skilled manner The NMC has also outlined standards of practice for nurses when administering medicines, including blood components, in Standards for Medicines Management (NMC 2008). As this document states, administering medicines is not a mechanistic task and the same criteria apply to blood components. It requires thought and the exercise of professional judgement in order to promote and safeguard the interests and well-being of the patient. The General Medical Council (Good Medical Practice, GMC, 1998) requires doctors to: Make the care of patients their first concern Respect the right of the patient to be fully involved in decisions about their care Keep their professional knowledge and skills up to date Recognise the limits of their professional competence Work with colleagues in ways that benefit patients interests. Other staff groups, which have no specific governing body, are required to adhere to policies and standards of practice specified by their hospital. However, they may find the NMC and GMC documents equally relevant. The NMC Code of Professional Conduct and Standards for Medicines Management

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can be found at www.nmc-uk.org The Good Medical Practice, guide can be found at www.gmc-uk.org

ACTIVITY 5
Note down any factors that might affect your ability to adhere to safe standards of professional practice at all times.

Key points
1 Human error is the greatest potential risk associated with blood transfusion in the UK. 2 The majority of transfusion errors involve the administration of a unit of blood intended for another patient. 3 The most common errors in the transfusion process are: The blood sample is drawn from the wrong patient Patient details are recorded incorrectly on the blood sample or the blood request form The incorrect unit is collected from the blood refrigerator The formal patient identity check at the bedside is omitted or performed incorrectly at the time of the administration of the blood component. 4 Blood transfusion is a complex process that involves a number of personnel and departments. Each has the responsibility to ensure that standards, guidelines and procedures are correctly followed at all times.

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2
Blood Group Serology
SHOT Summary
The transfusion of an incompatible blood component is the commonest cause of acute transfusion reactions. Cases of ABO/RhD incompatible transfusion have consistently been reported to SHOT since the beginning of the reporting scheme. This has resulted in avoidable fatalities and cases of severe morbidity. In female patients who received the wrong RhD group this may lead to major problems during pregnancy and the birth of children severely affected by haemolytic disease of the newborn. The purpose of this section is to help you understand the ABO and RhD blood groups and the importance of compatibility in the transfusion process. It also describes the basic blood grouping and antibody screen performed before a routine transfusion.

Learning outcomes
When you have completed this section, you should be able to: 1 Understand the importance of blood group systems in the provision of compatible blood. 2 Be aware of the options available to the hospital transfusion laboratory for the supply of blood to your patients. 3 Communicate this information to patients, relatives and less experienced colleagues.

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2.1

Blood group systems

A large number of different molecules are present on the surface of the red cells. The molecules the antigens determine the blood groups. There are over 100 different types of antigen but, for the purposes of safe transfusion practice, the most important are the antigens that produce the ABO groups. Also of importance is the RhD antigen which determines whether someone is RhD Positive (cells carry the D antigen) or RhD Negative (cells lack the D antigen). Antibodies may develop to each of these antigens if a patient is transfused with blood that is of a different group from their own. Transfused blood will almost never be completely identical with that of the patient unless they have pre-donated their own blood. It is therefore accepted in transfusion practice that there is an approximate 1 in 20 chance that a transfused patient will develop a red cell antibody after transfusion. This does not normally cause any problems, but does need to be taken into account when selecting blood on subsequent occasions.

2.2

The ABO blood groups

There are four different ABO blood groups. An individuals ABO group is determined by whether or not their red cells carry the A antigen, the B antigen, both A and B antigens or neither A nor B antigens (see Figure 4). Figure 4 ABO blood groups

Individuals develop ABO antibodies (immunoglobulins) against the antigens that are not present on their own red cells. Thus, group O individuals have, in their plasma, antibodies to both group A and group B. Group AB individuals have neither of these antibodies, as shown in Table 1.

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Table 1 Blood group antibodies

Blood Group A B AB O Makes antibody(ies) anti-B anti-A None anti-A & B

Table 2 ABO blood group frequencies in the UK population (Murphy & Pamphilon 2001)
% in the UK population A B AB O ABO Group 45% 9% 3% 43%

A and B antibodies are not made by newborn babies, but develop over the first few months. These antibodies have developed without the exposure to red cells of other groups so we describe them as naturally-occurring. If red cells carrying A or B antigens are transfused to an individual who has antibodies to these antigens, a severe immune reaction can occur because the donor red cells are not compatible with the recipient. This may be fatal. Figure 5 shows the blood group of the component that is ABO compatible with the blood group of the recipient. This illustrates that the blood component issued for a patient does not need to be of an identical blood group, but must be compatible. You can see from Figure 5 that group O red cells can be given to patients of any ABO group. In addition, you can see that group AB individuals can receive blood of any ABO group. Figure 5 Groups of red cells that can be safely transfused to patients of specific ABO groups

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The transfusion of only a few mLs of the wrong (incompatible) ABO group can trigger a massive immune response, leading to shock and disseminated intravascular coagulation. Patients may die from circulatory collapse, severe bleeding or renal failure within hours of receiving a small volume of blood. In an emergency, it may be necessary for the hospital transfusion laboratory to supply blood before a blood sample from the patient has been tested to determine the blood group. In a life-threatening situation, group O (usually RhD Negative) blood is supplied, as this will be suitable for all patients. A small number of units of group O RhD Negative blood are normally provided as stock for critical clinical areas, such as Accident & Emergency, so that transfusion can be commenced rapidly in particularly urgent cases. However, the hospital transfusion laboratory will supply blood of the patients own group as rapidly as possible in order to conserve stocks of O RhD Negative blood. Supplies of emergency O RhD Negative blood should not be used if the patients condition suggests that there is enough time to wait for the laboratory to provide blood of the patients own group (group specific). This is likely to take 10 - 15 minutes from receipt of the blood sample, provided that transportation between the laboratory and the clinical area is rapid. When time allows, blood should be issued after full testing of the patients blood sample. This will conserve stocks of group O RhD Negative blood and minimise the risk of any incompatibility due to other blood group systems. Fully crossmatch blood should be available within 30 - 40 minutes of receipt of the pre-transfusion sample in the laboratory. However, this will take longer if an antibody is found.

2.3 Transfusion of fresh frozen plasma, cryoprecipitate and platelets

Units of fresh frozen plasma (FFP) and platelets contain plasma, which will have antiA and anti-B antibodies present according to the group of the donor, but they do not contain large volumes of red cells. As your transfusion service may only supply platelets of group O and group A, you may commonly see that the group of platelets supplied does not match those of the patient. This is generally not important, as the volume of plasma given in a platelet transfusion is small. However, some units of Group O platelets contain particularly high levels of anti-A or anti-B, which may cause haemolysis. These units are NOT suitable for transfusion to patients who are Group A, B or AB and will be marked For Group O Recipient only. If you receive a unit of FFP or platelets for a patient which is not the same group as the patient and you have doubts about the compatibility, do not hesitate to discuss this with the hospital transfusion laboratory before transfusion. If the patient must receive a large volume of plasma (e.g. more than 1 litre in an adult), then plasma of the patients own ABO group must be used wherever possible. Platelet packs contain very small amounts of red cells. This may be enough to induce the

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formation of anti-D if RhD Positive platelets are given to a patient who is RhD Negative. This is only of concern if the patient is a female who may go on to have children, in which case the RhD Negative patient should receive RhD Negative platelets. An alternative, though less ideal solution is to give RhD Positive platelets, followed by an injection of anti-D immunoglobulin to clear the red cells from the circulation.

2.4

The RhD Blood Group

It is generally the case that an RhD Negative patient is given RhD Negative blood when being transfused. RhD Positive blood can stimulate the production of anti-D if transfused to an RhD Negative recipient. This will normally not cause any acute problem as the antibody will usually appear several days after the transfusion and will not lead to rapid red cell destruction. As RhD Negative blood is often in short supply, it may be necessary to use RhD Positive blood for the transfusion of RhD Negative patients. For certain patients, however, the development of anti-D can have serious consequences. It is particularly important to use RhD Negative red cells when transfusing RhD Negative females of childbearing potential because the transfusion of RhD Positive blood to an RhD Negative female child or woman might sensitise her to produce antiD. Anti-D might cross the placenta in any subsequent pregnancy and destroy the fetal red cells, thereby causing haemolytic disease of the newborn. Table 3 shows the blood group of the component that is RhD compatible with the blood group of the recipient.
Table 3 RhD compatibility
Acceptable blood group of component Blood group of recipient Red cells in additive solution RhD Positive RhD Negative RhD Positive or RhD Negative RhD Negative Fresh frozen plasma/ Platelets RhD Positive or RhD Negative RhD Negative

ACTIVITY 6
If you work in a clinical area where patients are regularly transfused, consider keeping a record of the ABO and RhD blood groups of at least 20 patients. What is the proportion of ABO groups among your patients? How does this compare with the proportion shown in? Table 2 on p. 23 What proportion of your patients are RhD Negative?

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2.5

Compatibility testing

When blood is required for a patient, the hospital transfusion laboratory must carry out a number of tests to select the most appropriate units. The patients blood sample is first tested to determine the ABO group and the RhD group. In addition, the patients plasma or serum is mixed with a range of red cells to determine if the patient has antibodies due to previous transfusion or pregnancy. This combination of tests is known as a Group and Screen or Type and Screen and is the most important part of the compatibility testing procedure. It takes the laboratory about 30 - 40 minutes to perform these tests following receipt of the blood sample. Once the ABO and RhD group is known and the antibody screen has been shown to be negative (as it is in 99% of cases), blood can be selected for the patient very quickly. This may be done by electronic issue, which is the selection of blood components by the laboratory computer based on agreed local protocols, or by a simple, rapid cross-match procedure, mixing the patients serum with the pack red cells and checking that there is no clumping in the tube (which is seen when blood is incompatible). If a patient is found to have red cell antibodies, however, finding compatible blood can be very difficult and time-consuming as blood must be selected that lacks the antigen to which the patient has developed an antibody. In some instances, for example, only 1 in 1000 units will be suitable. In most hospitals, emergency supplies of unmatched blood are available in certain locations, such as Accident & Emergency and the Labour Suite. This blood is group O RhD Negative. This can safely be given to any patient with a life-threatening haemorrhage if the provision of cross-matched blood from the hospital transfusion laboratory will take so long that the patients life may be at risk due to the delay.

2.6

Later provision of blood

Blood samples sent to the hospital transfusion laboratory will normally be retained for 5-7 days (depending on the individual laboratory) in case blood is needed at a later date. Therefore, a sample which has been sent for a Group and Screen only can be used for a cross-match if the need arises. The cross-match can be done rapidly as the initial testing (Group and Antibody Screen) has already been performed. Usually it is necessary only to telephone the laboratory giving the patients full identification (surname, forename, date of birth and unique hospital identifier) and your precise requirements (number of units, how soon and where they are needed). Some hospitals provide a facility for ordering through the IT system in case of emergencies, however, it is important to back this up with a phone call. Once a patient has been transfused, red cell antibodies may appear within days or weeks. For this reason a fresh sample may be needed. Table 4 shows the maximum time period between drawing a pre-transfusion sample and administration of the

27

blood in patients who may have been transfused in the past. The laboratory staff will remove or dereserve blood, which has been cross-matched but not transfused within a period of 48/72 hrs; (variations may exist regarding this time period in different hospitals). You should check your local policy in order to minimise the risk that you will give a unit to which the patient now has an antibody and also to make efficient use of stocks.
Table 4 Pre-transfusion testing times
Timing of Previous Transfusion 3 - 14 days 14 - 28 days 28 days - 3 months Samples to be taken Maximum 24hr pre-transfusion Maximum 72hrs Maximum 1 week

ACTIVITY 7
What group of blood do you think should be supplied for emergency transfusion if the patients blood group is unknown? Check your answer with that given in the activity answer section, which is at the back of the pack. Find out if emergency supplies of unmatched blood are kept in your hospital and, if so, how many units are stored at each site. With a group of colleagues, who are working through this learning pack, consider arranging a visit to your hospital transfusion laboratory. Find out how the laboratory staff deal with routine and urgent requests for blood and any problems they experience in providing compatible blood. The remaining sections focus on how you can ensure that no patient receives a potentially life-threatening incompatible transfusion.

Key points
1 The transfusion of an incompatible blood component is the commonest cause of an acute haemolytic transfusion reactions. This may be fatal. 2 The ABO system is the most important blood group system in transfusion because ABO incompatibility can cause the most acute and severe reactions. 3 RhD Negative females of childbearing potential should not receive RhD Positive components as this may put them at risk of having babies affected by haemolytic disease of the newborn. 4 The performance of the blood grouping and antibody screen tests is the most important step in the provision of compatible blood components. Knowing how long it takes your hospital transfusion laboratory to perform them will help you to ensure that, wherever possible, blood is ordered in sufficient time before it is required to allow these basic tests to be completed.

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3
Ordering Blood
SHOT SUMMARY
The distribution of errors has remained remarkably consistent since the SHOT scheme was launched. Between 20 - 30% of errors in the Incorrect Blood Component Transfused category have been related to prescription, sampling or requesting procedures. For example, the details on the blood request form and/or blood sample tube were incorrect, or the sample was taken from the wrong patient. The picture of near-miss reporting showed that sample errors were the most frequent category of reports (50%). These errors resulted from: Poor patient identification using only one or two identifiers Labelling of samples remote from the patient Addressograph labels used wrongly or placed in wrong patients notes Dilute samples taken from drip arms The purpose of this section is to help you to ensure that correct procedures for the ordering of blood are followed at all times.

Learning outcomes
When you have completed this section, you should be able to: 1 Inform patients of the expected benefits, risks and outcomes of transfusion. 2 Ensure that the blood request form is completed clearly and accurately. 3 Correctly label the blood sample tube. 4 Communicate effectively with the hospital transfusion laboratory to ensure that the right patient receives the right blood at the right time.

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3.1

Gaining Consent

Gaining consent for transfusion is one of a number of initiatives that have been promoted in recent years in order to improve transfusion practice. At present, there is no legal requirement in the UK and Ireland to gain specific consent from the patient for the transfusion of blood products. It is, however, usually sought as part of general consent. As stated in the Department of Healths Good Practice in Consent: Implementation Guideline, Patients have a fundamental legal and ethical right to determine what happens to their own bodies (www.doh.gov.uk/consent). Wherever possible, medical staff should discuss treatment options with the patient before reaching a decision to prescribe blood components. You should give the patient information on the benefits and risks of transfusion as well any alternatives that may be available for that particular patient, such as oral iron therapy or autologous transfusion. It is essential that you provide this information in a timely manner that is understood by the patient and that you check for understanding. As well as giving the patient the opportunity to discuss any concerns they may have regarding the transfusion, you should also check that they fully understand why a blood sample is being taken. For the consent process to be valid, the patient must be competent and have received sufficient information to make an informed decision. If the patient cannot communicate because for instance, he or she is unconscious, a paediatric patient or incompetent at the time, it is essential that you explain the proposed transfusion treatment to the patients relative or carer. It must be stressed however, that consent issues should not delay necessary transfusion in an urgent situation. It is acknowledged that, for some patients, the transfusion of blood may be morally unacceptable. This is a complex issue that will be covered in later units in the Better Blood Transfusion Programme. You may, however, wish to discuss with your clinical manager how the transfusion needs of these patients might be met within your hospital. A survey of patients' attitudes to transfusion revealed that patients primary concern is the possibility of contracting HIV from a blood transfusion (Gray & Murphy, 1993). The estimated risks of transfusion-transmitted infection (TTI) for the UK population are shown in Table 5.
Table 5 Estimated risks of transfusion-transmitted infection (Barbara & Flanagan, 1998)
Infectious agent transmission by transfusion HIV Hepatitis B Hepatitis C Estimated risk of <1:4 850 000 ~1:850 000 <1:50 000 000

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Whilst informing the patient about transfusion is a duty normally undertaken by the doctor, patients will often raise their concerns with other members of staff directly involved in their care. The nurse practitioner has a professional duty to ensure that they have an adequate knowledge of transfusion-related issues or can access the information and support required by patients undergoing transfusion therapy. Patient information leaflets have been developed by the National Blood Transfusion Services and are now available. There are a number of websites available to help your patients access relevant information on the transfusion of blood components, including:

Scottish National Blood Transfusion Service http://www.scotblood.co.uk National Blood Service http://www.blood.co.uk National Haemovigilance Office (NHO) http://www.giveblood.ie British Blood Transfusion Society http://www.bbts.org.uk Handbook of Transfusion Medicine http://www.transfusionguidelines.org.uk

ACTIVITY 8
What questions about transfusion have you been asked by your patients? How did you respond to them? Are there any questions you found difficult to answer? Review any patient information materials relating to blood transfusion that are available in your clinical area or that have been produced by other clinical units in your hospital. Can you suggest any ways in which they might be improved?

3.2

Completing the blood request form

The blood request form should include the following information about the patient: First name(s) Last name Date of birth Gender

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 Unique Patient Identity Number (NHS or CHI number) Hospital/ward. You can use an addressograph label to provide this information on the blood request form provided it matches the detail on the patients identification band and the blood sample tube. It is good practice to ask that staff sign the addressograph label to indicate that they have undertaken a formal identification check. If a patient is admitted to the Accident & Emergency Department and cannot be readily identified, you should use their assigned unique hospital identity number on the request form. In the event of a major incident, you should use the patients Major Incident number for the purpose of identification. The following information should also be provided on every blood request form: Diagnosis/reason for request, including the nature of the procedure if the patient requires surgery Number and type of component required Special requirements e.g., irradiated blood Group and screen only (if appropriate) Date and time required. This information will allow the hospital transfusion laboratory staff to check the number of units requested against the standard ordering tariff or maximum surgical blood ordering schedule (MSBOS). A blood ordering schedule is used to ensure that blood is ordered appropriately (this topic is covered in more detail in Module 2: Blood Component Use, section 3.9). If a larger number of units are requested because of exceptional circumstances (e.g., pre-existing anaemia or bleeding), this should be stated on the request form. Some surgical procedures do not require blood to be cross-matched. However, the hospital transfusion laboratory will undertake a group and screen pre-transfusion test to determine the patients ABO and RhD group and screen for any antibodies that could react with the donor red cells. If a transfusion is subsequently required, blood can then be provided rapidly. Always state the date and time the blood is required. Never use an ambiguous term such as as soon as possible as this may not convey the urgency of the request and may make it difficult for the hospital transfusion laboratory to prioritise its workload. Every request form must include: Name of requesting doctor Signature of the individual who has drawn the blood sample. This signature should not be added until after the sample has been taken.

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The following information is useful to the hospital transfusion laboratory staff and you should include it on the request form if it is available in the patients case notes: Patients blood group Presence of known antibodies Date of last transfusion.

3.3

Taking the pre-transfusion blood sample

When a pre-transfusion test is requested, it is important to bleed only one patient at a time in order to reduce the risks of a patient identification error occurring. It is vital that you positively identify the patient, you should follow the procedure detailed below. Step 1 before drawing the sample, ask the patient to tell you their: First name Last name Date of Birth. Check this information against the patients identification band for accuracy Step 2 Check the patients ID number on the identification band against the patients medical notes or completed blood request form. All unnamed patients (e.g., those in A&E) must be identified with a unique identification number and gender at every step in the transfusion process. If you are taking a sample for pre-transfusion testing from a patient in the out patient setting where they may not be wearing a identification band, please refer to your local hospital policy for identification of the patient. If the patient is unconscious or unable to verify their identity, it is important to ask a relative or a second member of staff to verify the patient identification details and follow the hospital policy on identification of the unconscious or compromised patient. Collect 5 ml (minimum 1 ml for neonates or very young patients) of blood into the appropriate sample tube. Hand write the compatibility sample tube clearly and accurately (it is essential to spell the patients name correctly and consistently) with the following information, at the patients bedside after you have drawn the blood sample: First name(s) Last name Date of birth Unique Patient Identity Number (NHS or CHI number) Hospital ward Date

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 Signature of person drawing the sample. Current BCSH guidelines recommend that you do not use addressograph labels on a blood sample tube this practise is more likely to result in inadequate patient identification. Never pre-label the compatibility tube (i.e., do not write the details on the sample label in advance of drawing the blood). Pre-labelling of sample tubes has been identified as a major cause of patient identification errors that can lead to fatal transfusion reactions. Figure 6 shows an example of a specimen label for a blood sample tube for compatibility testing.
Figure 6 Example of a specimen label for a blood sample tube for compatibility testing (EDTA = ethylene-diaminetetra-acetic acid)
BLOOD TRANSFUSION EDTA 4.5 ml Surname: Firstname: DOB: Hosp No: Date:

Gender: Hosp & ward: Sign:

A fresh blood sample for pre-transfusion testing will be required from any recently-transfused patient (i.e., within the previous 14 days) who has been transfused more than 2 days previously and for whom more blood is needed (see section 2.6). The patient may have formed antibodies in the interim and a fresh blood sample is essential to ensure that they do not receive blood, which is now incompatible.

ACTIVITY 9
Find out which type of blood sample (serum or EDTA) is required for pre-transfusion testing in your clinical area. The next five times you take a blood sample, evaluate your own practice in relation to any written procedures in your clinical area and to the guidelines above. Can you identify where potential errors could occur, particularly when under pressure? Do you ever take any shortcuts? Are there written procedures in your clinical area for completing the blood request form and taking a blood sample? Consider reviewing these procedures, can you suggest ways in which they could be improved? If there are no written procedures or you feel they need to be revised, discuss with your clinical manager and colleagues any action that may be required.

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3.4 Communicating with the hospital transfusion laboratory

It is essential that the urgency of the request for blood components is accurately communicated to the hospital transfusion laboratory and that clear instructions are given about when and where the components are required. When a routine transfusion is required, you should send the blood sample and completed request form to the hospital transfusion laboratory with the appropriate request date/time completed on the form. If the transfusion is required urgently, it is imperative to notify the hospital transfusion laboratory by telephone and to send the blood sample and completed request form via the most rapid method. The urgency of the request should also be clearly stated on the request form. You should follow the advice given in your local major haemorrhage protocol. The selection of the most appropriate component for a patient involves a high level of skill and scientific knowledge. It is better to let the hospital transfusion laboratory BMS decide on the best pre-transfusion procedure in an emergency situation. Your ward or departmental blood fridge may contain supplies of O RhD Negative blood for use in life threatening haemorrhage and further supplies of this or other group compatible blood can be obtained rapidly. This will prevent the patient being put at risk by waiting for cross-matched blood that can take up to 45 minutes to prepare when group-specific unmatched or group O Negative blood is a more appropriate option. The HTL must be notified immediately if this blood is removed from a blood fridge to ensure rapid replacement of emergency units so that future demands are not compromised. Traceability documentation must be fully completed and returned to the HTL as per local policy. If the patient is transferred to another part of the hospital before the blood component being issued to the clinical area, you should notify the hospital transfusion laboratory of the change in circumstances so that there are no delays in delivering the blood component.

ACTIVITY 10
Look at the blood request form used in your hospital. Has it been designed in such a way that you can readily include all the details given on pp. 30 -33. Does your request form enable you to convey the urgency of a request for blood clearly and without ambiguity? When you visit the hospital transfusion laboratory, find out the timings associated with the release of group O RhD Negative and group-specific unmatched blood.

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Would you suggest any modifications to your hospitals blood request form? If so, discuss your ideas with your clinical manager and colleagues and consider whether it is appropriate to make a formal request to the Hospital Transfusion Committee, through your local facilitator, to revise the form. Identify if your hospital has implemented a major haemorrhage policy. What transportation methods are available in your hospital for urgent samples?

The hospital transfusion laboratory should reject request forms and blood samples that are inadequately labelled: i.e., do not show full patient details, the location of the patient or the name of the doctor requesting the blood. Samples that are completely unlabelled, have been previously labelled with another patients details or have been labelled with an addressograph label will be discarded. You should check your local policy.

ACTIVITY 11
What are the regulations for dealing with inadequately completed blood request forms or blood sample tubes in your hospital? In what circumstances would the hospital transfusion laboratory discard an inadequately labelled blood sample? Do you understand why this action is necessary? Does your hospital have a specimen amendment form? If not or if you feel that the existing form could be improved, talk to your manager and colleagues about making a formal request to the Hospital Transfusion Committee to consider developing a form or revising the existing form. Once the hospital transfusion laboratory has selected the appropriate blood components, they will be available for collection. Section 4 deals with all aspects of the collection, delivery and storage of blood components before transfusion.

Key points
1 Patients requiring transfusion should be informed of the benefits, risks and expected outcomes of transfusion and given the opportunity to discuss their proposed treatment. 2 The blood request form should be completed fully and accurately. 3 The blood sample tube for compatibility testing should be labelled at the patients bedside after the sample has been taken. It should never be pre-labelled. Pre-labelling has been identified as a major source of patient identification

36

errors that can lead to fatal transfusion reactions. 4 Effective communication with the hospital transfusion laboratory is needed to convey the urgency of the request for blood and to ensure that blood components can be provided at the required time in the required place.

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4
Collecting, Delivering and Storing Blood Components
SHOT SUMMARY
The withdrawal of an incorrect component from the storage site remains the most frequent point of error reported to SHOT. In each case, it was followed by misidentification at the patients bedside. In the near-miss category errors related to incorrect storage of components, during transportation or on the wards, resulting in subsequent wastage of the components involved. The purpose of this section is to help you to ensure the safe and efficient collection, delivery and storage of blood components during the period from their issue from the hospital transfusion laboratory to their administration to the patient.

Learning outcomes
When you have completed this section, you should be able to: 1 Follow the correct procedures for checking the patients identification details and the traceability label attached to the blood component to ensure that the correct pack is withdrawn from its storage location. 2 Document the collection and delivery of blood components and their removal from the ward or theatre refrigerator. 3 State the correct temperature ranges for the storage of blood components. 4 Ensure that blood components are kept in the correct storage conditions during transportation and in the clinical area before administration to the patient. 5 Follow the correct local procedures for returning unused blood components to the hospital transfusion laboratory.

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4.1

Documentation

The EU Blood Directive 2002/98/EC passed into UK Law on 08/02/2005 as the Blood Safety and Quality Regulations( 2005) (BSQRs). These legally binding regulations require evidence that staff involved in the blood collection process have received training, which is competency based. A trained member of staff should check and sign that the correct blood has been delivered to the clinical area. The removal of a blood component from the refrigerator, or its return to the refrigerator, should normally be documented either electronically or manually. As a minimum, the following information should be recorded: Donation number of the pack Date and time of removal/return Signature. This ensures that all red cell units available for transfusion have remained under approved storage conditions.

4.2

Collecting or delivering blood components

Collection of blood components from the hospital transfusion laboratory or a satellite refrigerator
The procedure for collecting a blood component is the same regardless of whether you are collecting blood from the hospital transfusion laboratory or from a satellite refrigerator in the clinical area. When collecting a blood component you must ensure that the details on the blood collection form or alternative local documentation matches the information on the patients wristband before passing the request to the person collecting the blood component. The patient details must include the following: First name(s) Last name Date of birth Unique Patient Identity Number (NHS or CHI number) Gender Ward. On collection of the component from the hospital transfusion laboratory or satellite refrigerator the patients identification details must be checked against the patient traceability label attached to blood component. For each subsequent blood component collected the process must be repeated, i.e., a new blood collection form must be completed or telephone request made.

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Receipt of blood components in the clinical area

Every hospital should have procedures in place for notifying the nurse in charge of the ward, theatre or other treatment area that blood or a blood component has been delivered from the hospital transfusion laboratory. This will eliminate any confusion about whether or not the blood has arrived and allow staff to place the component in the correct storage conditions or administer it within the correct time period.

ACTIVITY 12
Review your local policy and procedures for checking blood components when they are collected from the hospital transfusion laboratory or removed from, or returned to, the satellite refrigerator. Can you identify any potential for errors to occur? If yes, identify any action that could be taken to prevent the collection of the incorrect component for a particular patient. Discuss your ideas with your clinical manager and colleagues.

4.3

Storing and transporting blood components

Blood components have a finite shelf-life that depends on the individual component and the conditions under which it is stored. The storage of blood components outside the recommended temperature range may result in loss of function, bacterial overgrowth, or both. Bacterial contamination may be fatal for the recipient of the blood component. When you take delivery of blood components, it is essential to ensure that they are stored correctly until they are administered to the patient.

Red cells
Red cells must be stored at 4C (+2C). Temperatures below +2C cause haemolysis. The transfusion of haemolysed cells may be fatal. Red cells can be stored in the hospital transfusion laboratory for up to 35 days. Unused red cells that have been out of refrigeration and have not been transfused for reason within four hours, must be returned to the blood bank with clear documentation confirming the length of time out of refrigeration. Once out of the cold chain, the pack will slowly warm to ambient temperature, increasing the risk bacterial proliferation and red cell metabolism. Blood bank quality procedures must ensure that all red cell units available for transfusion have remained under approved storage conditions. Hospital transfusion laboratory quality procedures must ensure that all red cell unit available for transfusion have remained under approved storage conditions

Transportation
If the transportation of red blood cells between the hospital transfusion laboratory and the clinical area will take longer than 10 minutes, they must be

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transported in a cool box that has been validated for this purpose.

The blood refrigerator

Red cells must be stored at 4C (+2C) in an authorised blood fridge with an audible alarm system and functional temperature recorder - never in domestic/drug fridge. This ensures that al red cell units available for transfusion have remained under approved storage conditions. To avoid wastage, only one unit of red cells should be removed from the refrigerator at a time unless the rapid transfusion of large quantities of blood is required. The HTL must be notified immediately if emergency blood is removed from a blood fridge to ensure rapid replacement of emergency units so that future demands are not compromised. If no authorised blood refrigerator is available and the red cells cannot be administered, you should return the unit to the hospital transfusion laboratory for storage until required. Blood refrigerators should never be opened unnecessarily or left ajar as this may cause unacceptable temperature fluctuations. Nothing other than donor red cells should be stored in the blood refrigerator, even for brief periods. If the alarm on a blood refrigerator sounds, it is the responsibility of the staff in the ward or theatre to immediately notify the hospital transfusion laboratory staff to allow them to take action to safeguard the contents of the refrigerator. Some hospitals may have an alarm system that automatically notifies the transfusion laboratory. Domestic refrigerators are not suitable for storing blood components, even for short periods of time, because there can be a wide variation in temperature inside them. This may, for example, cause red cells to freeze and then thaw, thus causing them to break down (lyse).

ACTIVITY 13
Review your local policy or procedure for monitoring the temperature in the blood refrigerator in your ward, theatre or clinical area. Is the procedure followed at all times? If not, discuss with your clinical manager what action needs to be taken to resolve this problem.

Fresh frozen plasma and cryoprecipitate

Fresh frozen plasma (FFP) and cryoprecipitate can be frozen without loss of their functional activity and can be stored in a frozen state (30C) for up to two years. These components are thawed rapidly at +37C in conditions that minimise pack contamination and protein damage.

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Thawed fresh frozen plasma and cryoprecipitate do not need to be transported in cool boxes and can be stored for up to 30 minutes at room temperature. To maximise the benefit to the patient, these components should be infused as soon as possible after thawing. However, you must complete the administration of the unit within six hours of thawing and within four hours of spiking the pack. Thawed components cannot be refrozen. FFP or cryoprecipitate that is not used within 6 hours of thawing must therefore be returned to the hospital transfusion laboratory for documented destruction. Since June 2005 FFP, FFP and cryoprecipitate for neonatal use (paedipacks) and for children under 16 years have been derived from imported plasma. These components are methylene blue treated as a pathogen reduction measure.

Platelets
Platelets require quite different storage conditions from red cells or FFP. They are stored for up to five days in the hospital transfusion laboratory at +20 +24C (controlled room temperature) on an agitating rack. Platelets must never be chilled as even brief exposure to low temperatures causes them to aggregate (irreversibly). They should therefore never be placed in a refrigerator. Platelet packs are made of breathable plastic as the platelets are metabolically active cells and must exchange O2 and CO2. Enclosing the platelet pack in an outer wrapper for more than a few hours will lead to deterioration in platelet function. Platelets are agitated throughout their storage phase to prevent irreversible aggregation. Platelets must be transported at room temperature. Platelets must be kept away from heaters and direct sun as temperatures above the recommended range may cause rapid proliferation of bacteria. Since platelets are stored at room temperature, any bacterial contaminant can grow rapidly. Bacterial contamination of platelets is the commonest cause of septic transfusion reactions. Once the pack is spiked, the infusion must therefore be completed within 4 hours (platelets are usually given over a period of 3060 minutes).

ACTIVITY 14
Review your local policy and procedures for storage, in the clinical area, of blood components that cannot be transfused within the specified time period. Have you ever found that blood components have been stored inappropriately, for example, in the ward or theatre drug refrigerator? What action do you think is needed to prevent this from recurring? Discuss your ideas with your manager and other members of the clinical team.

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4.4

Unused blood components

All unused blood components should be sent back to the hospital transfusion laboratory so that their return and subsequent reissue or destruction can be recorded. An unused component should never be discarded in the clinical area, even if the patient has died or the pack has already been spiked, but no infusion has been commenced. A permanent computer record is created for every unit of blood component that has been processed by the hospital transfusion laboratory and issued for transfusion. If the component is not returned to the laboratory, it will be assumed that it has been transfused to the patient for whom it was issued. It may be essential at a later date to identify all recipients of blood components from a particular blood donor. This may be because the donor has subsequently been diagnosed with an infectious disease that can be transmitted by transfusion.

Red cells
Unused red cells that have been out of refrigeration and have not been transfused for reason within four hours, must be returned to the blood bank with clear documentation confirming the length of time out of refrigeration. Once out of the cold chain, the pack will slowly warm to ambient temperature, increasing the risk bacterial proliferation and red cell metabolism. Blood bank quality procedures must ensure that all red cell units available for transfusion have remained under approved storage conditions. Hospital transfusion laboratory quality procedures must ensure that all red cell unit available for transfusion have remained under approved storage conditions Hospital transfusion laboratory staff should collect red cells that have been reserved for a patient and have remained in the refrigerator after the time for which they have been requested (normally 24 48hrs see local policy). It is important to notify the hospital transfusion laboratory when blood is no longer needed so that it can be returned to routine blood stocks more quickly, if it is suitable for reissue. This helps the laboratory to maintain optimum blood stock levels.

Fresh frozen plasma and cryoprecipitate

FFP and cryoprecipitate that have been issued but not used must be returned to the hospital transfusion laboratory for destruction. These components cannot be refrozen or reissued to another patient.

Platelets
Platelets that have been issued but not used in the clinical area should be returned to the hospital transfusion laboratory, as it may be possible to reissue them to another patient.

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ACTIVITY 15
Does your hospital have a method of recording the time the red cells are removed or returned to the refrigerator? What is the procedure for dealing with unused blood components in your clinical area? Compare it with the guidelines given above and identify any ways in which it could be improved. Discuss your ideas with other members of your clinical team and identify any action that might be required.

Key points
1 A major cause of the transfusion of an incorrect blood component is a failure in the procedure for checking the patients identification details, the documentation and the component at the time of its collection from the hospital transfusion laboratory or removal from the blood refrigerator. 2 A trained member of staff should check and sign that the correct blood has been delivered to the clinical area. 3 The removal of a blood component from an authorised blood refrigerator, or its return to the refrigerator, should always be documented with the unit number, the date and time of removal or return and the staff members signature 4 Red cells should be transported only in validated cool boxes and stored in authorised blood refrigerators. Fresh frozen plasma, cryoprecipitate and platelets should be transported and stored at room temperature. Platelets should never be stored in a refrigerator. 5 Red cell transfusion should be commenced within 30 minutes of removal of the pack from cold storage. Fresh frozen plasma and cryoprecipitate should be administered as soon as possible after thawing and always within 6 hours of thawing. Platelets should be infused within 23 hours of removal from agitated storage. In all cases, transfusion should be completed within 4 hours of spiking the pack. 6 Blood components that are requested and not used must be returned to the hospital transfusion laboratory so that they can be reissued or disposed of appropriately and accurate documentation can be maintained.

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5
Checking and Administering Blood Components
SHOT Summary
SHOT has reported that the single most important error contributing to the patient receiving the wrong unit of blood is a failure to check the blood component against the patient. Failure to undertake the final patient identification check is the commonest cause of the patient receiving the wrong blood. The causes included: Checking the component against the accompanying documentation rather than the patient Remote checking of the component against the patient identification details at the nurses station or treatment room rather than at the patients bedside Failure to note discrepancies between the patient traceability label and blood component label where laboratory labelling errors had occurred. The purpose of this section is to help you to ensure that the final bedside check is always performed correctly and that the administration of blood components is undertaken in a safe and efficient manner.

Learning outcomes
When you have completed this section, you should be able to: 1 Explain the importance of meticulous checking of patient identification details, documentation and the blood component at each stage of the transfusion process. 2 Correctly undertake the formal patient identity check at the bedside before the transfusion of every unit in order to prevent the administration of an incompatible blood component to a patient. 3 Select and correctly use the appropriate equipment when administering blood or blood components. 4 Select and correctly use an appropriate infusion device, when indicated.

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5.1 Checking the component and the patient before transfusion

The patient identification check at the bedside is the last opportunity to detect an identification error and it is vital that its importance is recognised. A failure in the formal identity check of the component with the patient at the bedside not only puts the life of the patient at risk but also places the practitioner in breach of professional standards and guidelines.

Pre-administration Procedure
Step 1 involves ensuring that the component has been prescribed, if the patient has any special requirements e.g., irradiated blood, and if they require any concomitant drug e.g., a diuretic prescribed. Step 2 Check that venous access has been established, any delay may result in wastage of the blood component Step 3 entails undertaking a baseline observation check of the patient's temperature, pulse and blood pressure Step 4 involves checking the expiry date of the component and undertaking a visual inspection of the component for any signs of discoloration, clumping or leaks, as a damaged or expired component must not be used.

Should there be any discrepancy at this point, it is important that you do not proceed until they have been resolved.
This process must be repeated for each component administered.

Checking the patients identity

The most important part of the checking process is to check that the patient details on the blood component are identical to the details on the patient's identification band. This should then be confirmed (wherever possible) by a verbal identification check with the patient. At the time of applying the patients wristband on admission, it is essential to confirm that the patients identity is recorded accurately in the notes, on the addressograph labels and the wristband. The information should be confirmed verbally with the patient or next of kin wherever possible. Guideline on the Administration of Blood Components (BCSH 2009) found no unequivocal evidence to support either a one or two person checking procedure. As a minimum, one registered healthcare professional must perform the checking/administration procedure next to the patient. If local policy requires a two person checking procedure, each person should complete all the checks independently (double independent checking). It is essential to adhere to the checking procedures specified in your local hospital guidelines in order to prevent a potentially fatal transfusion reaction and

46

to ensure that the following identification procedure is undertaken beside the patient for each blood component that is transfused. SHOT has stressed that the environment in which the transfusion is conducted must provide adequate working space and allow staff responsible for the bedside check to carry out an uninterrupted checking procedure. If you are interrupted in the checking procedure you must start again. Step 1 it is vital that you positively identify the patient. This can best be achieved by asking the patient to tell you their: First name Last name Date of Birth. Check this information against the patients wristband for accuracy. In the unconscious patient (or in paediatric practice) it is imperative to verify the patient identification details with a second member of staff. In unidentified patients in the A/E department the unique identification number should be used at all times during the transfusion process Step 2 check the patients first name, surname, date of birth, hospital number and gender details on the compatibility/traceability label attached to the blood component against the patients ID band. Step 3 you should check that the blood group and the donation number on the traceability label are identical to the blood group and donation number on the blood component This process must be repeated for each component administered.

Should there be any discrepancies at this point, it is important that you do not proceed until they have been resolved.
A different but suitable blood group, which is compatible with the patient, may have been issued. If you are unsure about the suitability of the component check with the HTL before transfusing. In the case of a patient receiving several units of red blood cells, FFP, platelets or cryoprecipitate, which will be infused simultaneously or in rapid sequence, e.g., plasma exchange or massive transfusion, it is acceptable for the full sequence to be carried out for the first unit only if: All units are being checked in an uninterrupted process. All units, which are being checked, will remain at the patients bedside until they have been transfused. No units for any other patient have been brought, or will be brought, to the patients bedside. Any discrepancies noted e.g:, wrong date of birth after the blood has been issued, may necessitate the return of all the units to the hospital transfusion laboratory and the drawing of a further, correctly labelled blood sample.

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Figure 7 on p. 49 illustrates the steps in the final bedside checking procedure. Figure 8 on p. 50 shows the blood component label and traceability label. These pages can be photocopied and used as a teaching aide.

SHOT Case Study 1

Following a road traffic accident, several severely injured casualties were admitted to an Accident & Emergency department. The hospitals policy for the secure identification of unknown patients was not followed, resulting in a confusing combination of names and numbers. As a result, a group A unknown male was transfused with 27 units of group O red cells. The patient suffered no ill effects.

ACTIVITY 16
Review the policy in your hospital for identifying unknown patients. How would you prevent a similar error from occurring?

SHOT Case Study 2

During a routine inpatient transfusion at night, a group A patient received a few mLs of group A red cells. The patient was not wearing an identity wristband. Before setting up the transfusion, two registered nurses checked the unit of blood in the ward treatment room, in accordance with local policy. At the end of this process, they were interrupted by the need to attend to a patient. In the meantime, a further unit of blood was delivered to the treatment room. On returning, the nurse picked up the unit she thought she had checked and connected it to the patient. Minutes later, she realised that a final check had not been made and returned to the bedside to discover that the wrong unit had been put up. The transfusion was immediately stopped and appropriate action was taken. The patient suffered no ill-effects.

ACTIVITY 17
Review the factors that contributed to this incident occurring. How could this error have been prevented?

SHOT Case Study 3

Two patients being transfused in the outpatient setting shared the same drip stand. The lines became entangled and a unit of red cells for one patient ended up being transfused to the other patient. Fortunately, the unit was ABO/Rh compatible. Hospital policy for the checking of transfusions was not followed.

SHOT Case Study 4

A patient requiring outpatient transfusions received the wrong ABO compatible unit. The circumstances leading up to this mis-transfusion included placing the case notes on an empty bed in anticipation of the patients arrival and asking the patient to confirm identification details with a Yes/No answer (closed question) rather than requesting the patient to recite their name and date of birth. Again,

48

hospital policies were not followed. In neither Case Studies 3 or 4 was the patient wearing an identification band.

ACTIVITY 18
Consider all the factors that might have contributed to the incidents outlined in SHOT Case Studies 14. Does your hospital have a policy in place for dealing with outpatient transfusions? If not, consider discussing with your clinical manager any action needed to ensure that outpatients are not at risk of receiving the wrong unit of blood.

ACTIVITY 19
Although developed specifically for nurses, the NMC document Standards for Medicines Management (2008) is relevant to all practitioners administering blood components. Obtain a copy and read it now. The BCSH Guidelines on The Administration of Blood and Blood Components (2009) recommends that one registered practitioner should undertake the final bedside check. How do you feel about this recommendation are there circumstances when you feel this might not be appropriate?

SHOT Case Study 5

A health care assistant collected the wrong blood component i.e.: wrong patients name, date of birth and hospital number, from a satellite refrigerator. The formal identity check at the bedside was not adequately performed, resulting in the group O RhD Positive patient receiving two units of group A RhD Negative red cells. The patient developed a fever, haemoglobinuria, hypotension and cardiac problems which culminated in his admission to the intensive care unit. The patient died because of this incompatible transfusion.

ACTIVITY 20
Consider all the factors that might have contributed to the fatal incident described in Case Study 5, including hospital policies, ward procedures, staffing and training. How could this fatal error have been prevented?

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Figure 7: Patient against Component Checking Procedure This is the final opportunity to prevent a mis-transfusion. The checking procedure should be undertaken according to your local Hospital policy. You must undertake the check beside the patient for each blood component transfused. If you are interrupted during the checking procedure START AGAIN

Pre-administration Procedure
Step 1 CHECK The component has been prescribed Any special requirements e.g., CMV negative blood Any concomitant drug e.g., diuretic Venous access has been established Baseline observations: Temperature, Pulse/ Blood Pressure and Respirations Expiry date / time of component For leaks / discolouration / clumping of component

Step 2 Step 3 Step 4

CHECK CHECK CHECK

Administration Procedure
Step 1 ASK The patient to tell you their: First Name Last name DOB Check this information against the patients identification band for accuracy Step 2 Step 3 CHECK CHECK The patients first name, last name, date of birth, hospital number and gender details on the compatibility/traceability label attached to the blood component against the patients ID band That the information on the traceability label matches the details on the blood component: Donor component number Blood group RhD group

N.B. Be extra vigilant when checking the identity of the unconscious or compromised patient If there are any discrepancies DO NOT PROCEED contact your hospital transfusion laboratory.

In the case of a patient receiving several units of red blood cells, FFP, platelets or cryoprecipitate, which will be infused simultaneously or in rapid sequence, e.g., plasma exchange or massive transfusion, it is acceptable for the full sequence to be carried out for the first unit only, if: All units are being checked in an uninterrupted process. All units which are being checked will remain at the patients bedside until they have been transfused No units for any other patient have been brought, or will be brought, to the patients bedside.

49

Figure 8 Checking the Blood Component and the Compatibility/Traceability Label

Traceability Label The traceability label is generated in the hospital transfusion laboratory. It is attached to the blood component and contains the following patient information:

Last name, First name(s), Date of birth, Gender, Hospital Number/CHI Number, Hospital and Ward
The blood group, component type and date required are also included on the label. The unique donation number is printed on the compatibility/traceability label; this number must exactly match the unique donation number on the blood component label
Unique Donation Number This is the unique number assigned to each blood donation by the Transfusion Service and allows follow-up from donor to patient. The unique donation number on the blood component must exactly match the number on the compatibility label.

G101 609 597 229 N Red Cells

MACDONALD 11/07/1956 25 HILL STREET TOWN CENTRE

MORAG FEMALE

100198E

24/03/2009

O Rh POS

Red Cells

G101 609 597 229 N

C C

MACDONALD 100198E G101 609 597 229 N Red Cells

MORAG 1803905
G101 609 597 229 N

Blood Group This shows the blood group of the component. It does not have to be identical with the patients blood group, but must be compatible.

RED CELLS IN ADDITIVE SOLUTION

STORE AT 4OC 2OC (SAGM)

Volume 275 ml
INSTRUCTION
Always check patient / component compatibility / identity. Inspect pack for signs of deterioration or damage. Risk of adverse reaction/infection, including vCJD.
CT 664/3 CT 664/3 CT 664/3 CT 664/3

Rh D POSITIVE
Do Not Use After 23 APR 2009 23:59

O
SNBTS

Cautionary Notes This section of the label gives instructions on storage conditions and the checking procedures you are required to undertake when administering a blood component. It also includes information on the component type and volume.

CMV Negative
ETEGB005

LOT B108061161026B

REF C00107157B

Date Bled 19 Mar 2009

Expiry Date The expiry date/time must be checked. Do not use any component that is beyond the expiry date or time. Special Requirements This shows that patients special transfusion needs: eg, CMV-negative.

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SHOT Case Study 6

The incident occurred during a period of nursing night duty. Three patients on the same ward had been prescribed blood transfusions. One was in progress while the other two patients were waiting for red blood cells to arrive from the hospital transfusion laboratory. The red cells arrived for Patient X. The night sister and a nurse checked the component against Patient Xs notes, at the nurses station. The night sister was bleeped by another ward and left the nurse to put up the transfusion. Patient Y (blood group O Rh Positive) was transfused with the group A Rh Positive red blood cells intended for Patient X. When the nurse realised the error, she contacted the on-call locum and bleeped the night sister. When the locum arrived, he advised the nursing staff not to notify the on-call haematologist, explaining that 50 ml of blood wont do any harm. He then spigoted off the unit that had been partially given in error to Patient Y and reconnected it to Patient X, the intended patient. Both patients survived with no ill effects. Patient Y received no investigations appropriate to an ABO incompatible transfusion.

ACTIVITY 21
Case Study 6 summarises an incident recorded in the 199798 SHOT Report in which a total of seven errors were found to have been made before, during and after a transfusion. Identify as many as possible of the errors that occurred during this incident. Check your answer with that given in the activity answer section, which is at the back of the pack. Can you identify potential errors (similar to those described in Case Studies 5 and 6) that could occur in your area? How could these be prevented? Discuss your ideas with your transfusion practitioner/haemovigilance officer or clinical manager and agree any action needed to ensure that the correct procedures are in place for checking the patient, the component and the documentation before transfusion and that they are consistently and correctly followed by all staff.

5.2

Administering blood components

You must ensure that you wash your hands and follow your local infection control policy when administering blood components.

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Venous access devices

Blood can be given successfully given through a needles as small as 23 gauge however the gauge selection should be dependent on the size of the vein and the desired speed at which the blood is to be transfused. Many transfused patients have venous access established by the use of short-term or indwelling central lines. These are generally suitable for the transfusion of blood components. When a multi-lumen catheter is used, the lumen specified for blood components should be used for transfusion. When a very rapid transfusion is to be administered through a central catheter terminating in or near the right atrium, the blood should be warmed. However, this is unnecessary for routine transfusion. Other infusion fluids (with the exception of 0.9% saline or 4.5% albumin) should not be run simultaneously through the same lumen as the blood component. The use of a Swan-Gantz sheath is a safe and effective means of giving a rapid transfusion. However, the use of Swan-Gantz catheters for blood transfusion is not recommended: as the tip of the catheter is high in the pulmonary artery, the use of a Swan-Gantz catheter may cause potential problems arising from the delivery of cold, acidotic blood directly to the pulmonary arterial system.

Blood administration sets

Blood components must be transfused through a blood administration set with an integral mesh filter. The filter removes macroaggregates, composed of white cells, platelets and coagulum, which can obstruct the cannula. This is particularly important in neonatal practice. It is not acceptable to draw blood components directly into a syringe to administer to a baby without an integral filter between the blood component and the syringe or between the syringe and the baby. Custom-designed infusion sets for neonates are available. Alternatively, platelet/cryoprecipitate administration sets are generally satisfactory for the administration of all blood components. It is unnecessary to prime the blood administration set with saline unless you feel you need to check the patency of the line. The use of additional bedside leucodepletion filters is unnecessary, as the leucodepletion of all blood components has been undertaken by the Blood Transfusion Services since 1999. There are no clear indications for the use of microaggregate filters. The routine use of these filters simply adds to the cost of transfusion. Platelets, fresh frozen plasma and cryoprecipitate must be administered through a normal blood or platelet/cryoprecipitate administration set. Do not transfuse platelets through an administration set that has previously

52

been used for red cells or other blood components as this may cause aggregation and retention of platelets in the line. Plasma protein solutions (5% albumin or 20% albumin) do not need to be infused through an administration set with a filter. A standard infusion set, as used for crystalloids or synthetic colloids, is suitable. For patients requiring ongoing transfusion, the infusion line should be changed every 12 hours. You should change the administration set following completion of the prescribed transfusion.

Other infusion fluids

Do not give blood through an infusion set that has been primed with dextrose. Dextrose solution should not be used to flush administration sets containing blood as this may cause haemolysis. Similarly, Ringer Lactate Solution should not be used to flush administration sets as this may lead to clotting of the transfused components in the infusion tubing. No pharmaceutical agent or solution other than 0.9% saline should be infused through a lumen that is used for the transfusion of blood components as this may damage the red cells, platelets or coagulation factors due to the pH, the osmolality or the chemical composition of the drug solution.

Transfusion rates
The transfusion rate for blood components is dependent on the condition of the patient. Red blood cell transfusion rates can vary from 510 minutes in-patients with acute blood loss to 4 hours in elderly patients with circulatory overload. The transfusion must be completed within four hours of spiking the blood component. Platelets, fresh frozen plasma and cryoprecipitate are normally transfused over a period of 30 60 minutes or as instructed. The transfusion must be completed within four hours of spiking the blood component.

5.3

Using infusion devices

Blood warmers
Occasionally, patients require blood that has been warmed before infusion. Warmed blood is most commonly required in: Large volume rapid transfusions Greater than 50 mL/kg/hour for adults 15 mL/g/hour for children Exchange transfusion in infants Transfusing a patient who has clinically significant cold agglutinins.

53

Always use a commercial blood warmer to warm blood and strictly follow the manufacturers guidelines. Never warm blood in a sink of warm water, on a radiator or by any other means.

Infusion pumps
Infusion pumps are commonly used in intensive care, high dependency units and paediatric settings to achieve optimum flow rates and their use in other clinical areas is becoming more widespread. If an infusion pump is used, always check the manufacturers specification to ensure that it is suitable for the infusion of red cells. Most infusion pumps of recent manufacture are suitable for use in blood transfusion. Administration sets used with these pumps for blood component transfusion must incorporate an integral mesh filter. If these filters are not available, you should use an alternative filter (e.g., Pall Ultipore microaggregate filter) in conjunction with the intravenous infusion set. As new pumps become available in your clinical area, you should consult the manufacturers instructions in order to assess their suitability for blood component administration.

Pressure devices
In large volume rapid transfusions, the use of a pressure device is recommended. The maximum pressure that should be applied to a blood component is 300 mmHg.

ACTIVITY 22
What kind of blood warmers are available on your clinical unit? Do you know how to operate them? If not, are they provided with clear and ambiguous instructions? If the instructions are unavailable, find out where you can obtain a copy. Look at the range of infusion pumps and pressure devices available on your unit. Do you know whether or not they are all suitable for the infusion of blood components? Check the manufacturers instructions or find out where you might obtain this information. Then share this information with your colleagues to ensure that they are all aware of the infusion pumps that are suitable for use in transfusion. All infusion devices should be regularly checked and maintained by trained personnel.

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Key points
1 A failure to perform a formal check of the component with the patient at the bedside is the single most important contributor to the transfusion of the incorrect blood component, which is potentially fatal. 2 The blood component should be checked for signs of damage or deterioration before transfusion. The expiry date should also be checked. 3 Blood components should always be transfused through a blood administration set with an integral mesh filter. This is particularly important in neonatal practice. For patients requiring ongoing transfusion, the infusion line should be changed every 12 hours. 4 Blood should be warmed only in a commercial blood warmer, which has been appropriately serviced and maintained.

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6
Monitoring the Transfused Patient
SHOT Summary
A number of reports to SHOT have highlighted the importance of monitoring patients during transfusion. Prompt recognition and management of transfusion reactions will improve patient outcomes. The purpose of Section 6 is to ensure that the procedure for monitoring the transfused patient is correctly followed at all times. Although it pertains primarily to nurses, clinical support workers and operating department practitioners, it will also be of interest to clinicians.

Learning outcomes
When you have completed this section, you should be able to: 1 Monitor patients appropriately before, during and on completion of a blood transfusion. 2 Correctly document each transfusion episode. 3 Recognise and take appropriate initial action in response to a possible transfusion reaction.

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6.1

Observing the patient

Ensuring the patients safety is the most important aspect of caring for a patient during a transfusion of blood or a blood component. It is therefore essential to adhere to the procedures stated in your local hospital policy/guidelines at all stages of the transfusion.

ACTIVITY 23
Check the procedure for monitoring the transfused patient in your hospital guidelines and also read the recommendations in the BCSH Guidelines on the Administration of Blood

Components.
It is essential to take baseline observations and to observe your patient during and after the transfusion in order to detect any adverse event as early as possible. This will ensure that potentially life-saving action can be taken quickly and efficiently. Adverse reactions can occur with all blood components so it is equally important to monitor patients receiving fresh frozen plasma, cryoprecipitate or platelets as those receiving whole blood or red cells. The majority of severe reactions most commonly present during the first 15 minutes of a transfusion. You must therefore observe all patients and, in particular, unconscious patients during this period and for the first 15 minutes of each subsequent unit.

Before commencing the transfusion

Before commencing the transfusion, you should: Make sure the patient has an identity band in place. Explain the procedure to the patient and check for understanding of the explanation. Advise and encourage the patient to notify you immediately if they become aware of any reactions such as shivering, flushing, pain or shortness of breath or begin to feel anxious. Ensure that the patient is in a setting where they can be directly observed. Ensure the patient has access to the nurse call system. Before commencing the transfusion of each unit, measure and record the patients vital signs on a separate observation chart (baseline recording no more than 60 minutes prior to the transfusion commencing) to ensure that any transfusion reaction can be immediately identified and managed: Temperature Pulse Blood pressure Respirations.

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During the transfusion

During the transfusion, you should: Monitor the patients temperature, pulse and blood pressure 15 minutes after each unit has commenced and record them on the transfusion observation chart or local transfusion documentation. Adjust the flow-rate so that you achieve the correct infusion rate over the prescribed time period. Temperature, pulse and blood pressure should be recorded hourly until compltion of the transfusion. Routine observations, including temperature, pulse, blood pressure, blood loss and urinary output should be continued in the unconscious patient throughout the transfusion. If the patient appears to be experiencing an adverse reaction, stop the transfusion and seek urgent medical assistance. Record vital signs regularly until the doctor has assessed the patient. Complete the transfusion of each blood component within four hours of the pack being spiked. If a component is not completed within four hours, discontinue its use and dispose of the remainder via the clinical waste system. In the case of a suspected transfusion reaction, do not discard the blood component and administration set, return them to the hospital transfusion laboratory for investigation. Change the blood administration set after 12 hours if the patient requires ongoing transfusion support. Document the start and finish times of each unit.

On completion of the transfusion

On completion of the transfusion, you should: Record the patients vital signs (temperature, pulse and blood pressure) on the transfusion observation chart or local transfusion documentation. Record the volume of blood transfused on the fluid balance chart (or 24-hour chart). Change the blood administration set when the transfusion is completed if other intravenous fluids are to be administered. It is not necessary to give a 0.9% saline flush. Remove or heparinise the cannula and dispose of the blood administration set if the transfusion is complete, in accordance with the procedure stipulated in your local hospital policy manual. File the transfusion documentation in the patients case notes. Keep empty blood component bags in the clinical area until the prescribed transfusion has been completed. If observation of the patient at completion of the transfusion reveals no evidence of an

58

adverse reaction, place the bags in the appropriate clinical waste for disposal. Although it is the policy in some hospitals to keep empty blood bags for 24 hours post-transfusion, this is rarely helpful. Adverse events occurring within 24 hours of completing a transfusion are rarely due to the transfused component if the patient has not experienced any ill-effects throughout the time of the transfusion.

ACTIVITY 24
Access a copy of your hospitals transfusion policy or guideline. Is the section on monitoring patients receiving a transfusion consistently followed in your clinical area? For example, do transfusions always take place in an area where patients can easily be observed? Do staff consistently perform the 15-minute check after the start of each component? Are there any factors that make it difficult for your colleagues to comply with the policy or guideline? Identify any changes needed to ensure that all patients are systematically monitored during transfusion in order to ensure the early recognition and management of a transfusion reaction. Discuss your ideas with members of your clinical team. If there are no written guidelines or procedures on monitoring transfused patients, suggest that a formal request might be made to the Hospital Transfusion Committee to consider developing a policy or guideline.

6.2

Documenting the transfusion

The BCSH Guidelines on the Administration of Blood Components recommend that a record of the transfusion of blood components should be kept in the patients medical case notes. A comprehensive and accurate record of the transfusion event and any adverse effects should be documented. The following information is required: Pre-transfusion laboratory results: e.g., haemoglobin level, platelet count Reason for transfusion Number of units/volume transfused Baseline observations Compatibility form/component type and number Prescription form Time transfusion commenced Duration of transfusion Signature of person(s) administering transfusion Transfusion chart/ local transfusion documentation/record

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 Fluid balance chart/ 24 hour chart Record of any adverse event/complication of transfusion Post-transfusion laboratory results: e.g., haemoglobin level, platelet count. Correct documentation is essential for a number of reasons, including the investigation of the cause of a serious adverse event such as a transfusion reaction and for lookback purposes if a donated unit is implicated in a transfusion-transmitted infection. The Blood Transfusion Service is required to trace the recipients of all blood components and products from that donation to ensure that appropriate follow-up measures can take place. Experience in hepatitis C lookback studies (Pawson, Rajan, Hazelhurst et al, 1999) has demonstrated poor compliance with the documentation process, it proved extremely difficult to trace patients who had received blood components or products that were potentially contaminated with hepatitis C. Hospital transfusion practitioners/haemovigilance officers and the Blood Transfusion Services regularly participate in audit and research and review patterns of blood usage in order to ensure best practice and identify problems such as a consistently high wastage rate within a clinical unit.

ACTIVITY 25
How is the transfusion of blood components documented in your clinical area? Does your documentation meet the standard recommended by the BCSH Guidelines? Undertake a case note review of the last two patients who received a transfusion in your unit. Was the correct documentation filed in the notes? If not, what action is needed to ensure the accurate and complete documentation of each transfusion episode? Share your findings and your suggestions for improvement with your clinical team and agree on any action required.

6.3

Initial management of an adverse event

An early and appropriate initial response to an apparent transfusion reaction will minimise any possible adverse consequences and may be lifesaving. The detailed management of haemolytic transfusion reactions, such as anaphylaxis and septic reactions, is covered in detail in the Module 2 pack, Blood Component Use. However, it is essential to be familiar with the action required to safeguard the patient while awaiting detailed advice from staff who are more familiar with the potential complications of transfusion. Any adverse event experienced by a patient in association with a transfusion should be considered as a possible transfusion reaction. The most commonly observed reactions are:

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 Volume overload (dyspnoea, hypertension and tachycardia) Fever Rash and/or itch Rigors.

Minor transfusion reactions

Note that the signs and symptoms of a minor transfusion reaction may indicate the start of a major reaction. It is important, therefore, to reassess the patient frequently (see section 6.1) in the event of any reaction and to proceed as for a major transfusion reaction if progressive deterioration is evident. Minor reactions include: Mild fever (temperature rise of up to 1.5C above the baseline) Rash without systemic disturbance Moderate tachycardia without hypotension. These may occur as a result of an immune response of the recipient to components in the transfusion (such as white cells or plasma proteins). It may be possible to manage these conservatively to allow the transfusion to be completed, as follows. Stop the transfusion and notify the doctor. Check the patient identity against the compatibility/ traceability label. Rapid deterioration should be managed as a major transfusion reaction (see below). Urticaria and itch generally respond well to antihistamines. Once you have administered the antihistamine, the transfusion can be recommenced if the patient is otherwise stable. In the absence of other features, a patient experiencing a mild fever may respond to paracetamol or aspirin and tolerate the remainder of the transfusion at a reduced rate. Regularly transfused patients who experience recurrent febrile reactions may benefit from an antipyretic before transfusion. Aspirin should not be given to thrombocytopenic patients as this may lead to bleeding.

Major transfusion reactions

Severe reactions include: Hypotension and/or dyspnoea, which may be early signs of anaphylaxis Haemolysis (which may present with back pain, muscle aches, rigors, dark urine, hypotension) Septic shock.

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Many of these reactions may present with fever as an early manifestation. A temperature of >38.5C, especially if associated with marked tachycardia (>120/min) and/or hypotension, should therefore be regarded as a potential severe reaction. The transfusion should be stopped, pending detailed assessment. If you suspect a major transfusion reaction:

Stop the transfusion and urgently inform the doctor.

Call the resuscitation team if cardiorespiratory arrest occurs or the reaction appears life-threatening. Remove the blood component and administration set, but keep the line open with 0.9% saline to provide venous access for any drugs or resuscitation fluids required.
Check the patient identity against the traceability label

If the patient is conscious, reassure them about the situation and keep them informed about the treatment and action to be taken. Maintain close observation and monitoring of the patient, as dictated by their clinical condition, including temperature, pulse, blood pressure, blood loss and urinary output. Inform the hospital transfusion laboratory and contact the Duty Haematologist about the investigation and further management of the reaction. In the event of a suspected transfusion, return the blood component and administration giving set to the hospital transfusion laboratory with new blood samples (10 mL clotted and 5 mL EDTA) from the patients opposite arm. Clamp off the administration set, cover the end and wrap it in an empty specimen bag (or similar). Sheathed or unsheathed needles must not be left on the line when this is returned to the hospital transfusion laboratory. Return any remaining un-transfused units to the hospital transfusion laboratory in order that their compatibility can be confirmed. If available, complete an appropriate Transfusion Reaction Notification form and send it with the blood sample tubes to the hospital transfusion laboratory. If a notification form is unavailable, send a brief note of the patients details, the nature and timing of the reaction and details of the component being transfused. Document the adverse event in the patients case notes.

In the event of a serious transfusion error, you must inform your line
manager and the Consultant Haematologist once appropriate action has been taken to safeguard the patient. The staff involved in the incident should be offered relevant education or training, as necessary.

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Adverse reactions in the anaesthetised patient

Classical signs of an adverse reaction to transfusion may be masked in anaesthetised patients. Clearly, they are unable to report any symptoms related to a reaction. Due to the anaesthetic agents used, they may not demonstrate the changes in heart rate, blood pressure or temperature associated with an adverse event. For this reason, extra vigilance is required when transfusing an unconscious patient. Changes in peripheral perfusion, core temperature (falling or rising), oxygenation, skin colour, acid-base balance may be indications of a transfusion reaction. It may be necessary to stop the transfusion for a time in order to allow the anaesthetist to assess the patient for other possible causes of the changes noted.

ACTIVITY 26
Review the procedure in your clinical area for the initial response to a transfusion reaction. Can you suggest any way in which it could be improved? If no specific procedure or protocol exists, develop a simple flowchart to indicate an appropriate response to apparent adverse reactions. Discuss it with other members of your clinical team. Locate your Transfusion Reaction Notification form and ensure that you know how to complete the documentation. If you would like more information about transfusion reactions, you should access the Handbook of Transfusion Medicine. http://www.transfusionguidelines.org.uk Key points 1 Inadequate monitoring of the patient may result in lifethreatening delays in the recognition and management of a severe transfusion reaction. 2 Each transfusion episode should be documented fully and accurately on the transfusion observation chart/ local transfusion documentation. 3 If a severe transfusion reaction is suspected the transfusion should be stopped immediately and urgent medical advice sought.

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7
Paediatric Transfusion
SHOT Summary
The SHOT working group has highlighted the importance of transfusion events in patients less than 18 years of age; a disproportionately high frequency of errors was reported in this age group of recipients. The majority of the adverse events were categorised as Incorrect Blood Component Transfused events. The content of each of the preceding sections is equally applicable to paediatric practice. The transfusion process however, may require certain modifications when dealing with children, particularly neonates and infants. This section covers some special features of paediatric transfusion, but should be read in conjunction with the earlier sections.

Learning outcomes
When you have completed this section, you should be able to: 1 Identify the specific requirements of paediatric patients requiring transfusion. 2 State the particular precautions that need to be taken in the identification and monitoring of paediatric patients, particularly neonates and infants.

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7.1

Blood group serology

The basic serological rules of compatibility are also applicable to children. However, when transfusing neonates or young infants (<34 months), it is generally accepted as best practice to cross-match the blood against the maternal blood sample. This is because any blood group antibodies present in the neonate will have come from the mother via the placenta. Neonates do not make any red cell antibodies, other than in very rare cases. In the absence of a maternal sample, it is extremely important that the blood sample sent from the baby is sufficiently large to allow full pretransfusion testing to be performed. This will require approximately 1 mL of blood. If the laboratory is sent an inadequate sample, some tests may have to be omitted and the laboratory staff may therefore not be able to identify that the blood may be incompatible.

7.2

Patient Identification

SHOT reporting has highlighted the importance of patient identification in the paediatric setting was highlighted. It has been recognised that errors due to failure to identify patients at the time of sampling and administration lead to the wrong blood incidents. The formal patient identity check at the bedside, using the wrist or ankle name band, is essential to prevent a mis-transfusion occurring in the paediatric setting. All unnamed patients must be identified with a unique identification number and gender at every step in the transfusion process Whilst many children will be able to tell you their name and date of birth, at no time should this method of identification be the sole method of checking patient ID.

7.3 Ordering blood Communicating with the patient

Older children may have the same concerns about transfusion as adult patients. You should therefore be able to provide the same information as you would an adult patient and give them the opportunity to ask questions. Information given to younger children must be appropriate for their level of understanding. A simple explanation of the reason for the transfusion and what is hoped to be achieved by it (for example, to stop them bleeding, make them stronger, less breathless, etc.) may reduce fear and improve cooperation. Wherever possible, you must involve parent/carer in the consent process. Parents/guardians may have many more concerns about their child having a transfusion than they would have about being transfused themselves. Many parents/guardians, particularly of preterm infants, regard transfusion as a major intervention and may be angry and

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distressed if you have transfused their child without first discussing this with them. Biological parents may ask if they can donate blood to be transfused to their infant. In general, this is discouraged in the UK as the immunological and infectious risks associated with parentchild transfusion exceed those from normal unrelated volunteer donors. For example, the mother may have developed antibodies to the childs blood cells (red cells, white cells, or platelets) due to fetomaternal bleeding during pregnancy. Nevertheless, you must take time to find out what their main concerns are in relation to blood transfusion and to discuss what can be done to minimise any transfusion needs. Parents need to be given the opportunity to voice their concerns, to feel that they are being heard and taken seriously and to receive an appropriate explanation of why the use of their blood may not be best for their child.

Completing the blood request form

In dealing with neonates who have not yet been named, it is vitally important to state the babys sex, surname, date of birth and unique hospital identification number. If the baby is from a multiple birth, it should be clearly identified as Twin 1 or Twin 2, etc. and this should be applied consistently to each request, even if one of the babies dies. When the child is finally named, it is important for the laboratory to know that, for example, Twin 1 Smith is now Jack Smith as it will enable the staff to link the babys previous results with the new identity. It is important to advise the laboratory of the mothers details at the time of sending the first sample from a child under 34 months of age (e.g., add comment: baby of Jennifer Smith, DOB 12/12/82) as the laboratory may have relevant details of the mothers antibody status. If you know from the antenatal notes that the mother has a red cell antibody, state this on the request form.

Taking the pre-transfusion sample

As noted above, it is important to send a blood sample of sufficient volume for pre-transfusion testing. Before taking a sample for pretransfusion testing it is vital to positively identify the patient. Two members of staff should check the identification wrist/ankle band check the details against the relevant documentation. The sample tube must be labelled with all the details specified in Section 3, Ordering Blood. If the patient is a neonate requiring their first transfusion, also send a maternal sample, as maternal antibodies previously transferred to the baby via the placenta may cause a severe transfusion reaction. The antibodies will be more strongly expressed in the maternal blood than in

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the neonatal sample and are therefore more likely to be detectable on laboratory testing of a sample from the mother.

Cord blood samples

Mixing up of maternal and cord blood samples is a relatively frequent error which may be due to pre-labelling of sample tubes or, conversely, failure to label the samples as soon as they are drawn. This may lead to erroneous administration of Anti-D to the mother, or wrong grouping of the baby with subsequent transfusion of blood of the wrong group. Check that your labour ward policies acknowledge this risk and detail appropriate steps to ensure accurate identification of all samples.

Communicating with the hospital transfusion laboratory

Your Blood Transfusion Service may produce special products for infants or neonates. For example, the local policy may be to administer only components that have been tested and shown to be free of cytomegalovirus (CMV) infection. CMV can be transmitted by transfusion and can cause severe disease in certain susceptible patients, such as small preterm infants (e.g., <1500g birth-weight). For neonates who are likely to receive further transfusions within 4-5 weeks, it may be desirable to obtain a red cell donation that has been subdivided into multiple aliquots (Paedipacks) to enable the baby to receive several transfusions from a single donation.

ACTIVITY 27
Find out what your departmental policies are for the transfusion of infants or children with special requirements, such as CMV- negative units, and the procedure for ensuring that these are clearly communicated to the hospital transfusion laboratory.

7.3

Collecting, delivering and storing blood components

There should be no significant differences in these procedures in the transfusion of children. Infants or young children will often receive only part of a component, as transfusion volumes are determined according to body weight. Components must not be returned to storage once the bag has been spiked. Any transfusion from a spiked component must be completed within 4 hours of first spiking the bag. In this context, it is important to be aware that similar restrictions apply to the use of protein solutions, such as albumin or intravenous immunoglobulin (IV IgG). Once the bottle has been spiked, it must be used within 4 hours or discarded. If a blood component has been spiked but none of the content has been given to the patient, you must however, return the component with the

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administration set attached, and notify the laboratory that it is untransfused in order that the patients record can be amended. It is not necessary to return a part-transfused component to the hospital transfusion laboratory. Even if only a few mLs have been transfused to the patient, the component is regarded as transfused. A blood component issued for one patient must not be shared with another, even if the volume is adequate to meet the needs of both. It is extremely important that laboratory records accurately show the precise fate of each component. This may be required for subsequent patient tracing if a donor is found to have a transmissible infection and may also be informative if antibodies are subsequently found in the recipient. There may be occasional exceptions to the no-sharing rule. For example, some centres will use aliquotted Paedipacks to transfuse several babies from one donation. This is acceptable practice provided that both the laboratory records and the patient records accurately show the fate of the component, including batch number details. However, there is an extremely small risk that an infectious donor could infect several children in the same unit. Neonatal units frequently share a blood fridge with the Labour Ward which may stock O RhD Negative blood for use in the emergency situation (e.g., Emergency or Flying Squad blood), or blood for the mother of the infant. Be aware that these units may not be suitable for transfusion to a neonate. FFP/Cryoprecipitate: Are stored in frozen state (-30C) for up to 2 years. Thawed rapidly at 37C. Once thawed cannot be re frozen. After thawing and when FVIII replacement is not required, FFP/ Cryoprecipitate may be stored at 4C in an approved blood storage refrigerator before administration to the patients, so long as the infusion is completed within 24 hrs of thawing (Refer to local hospital policy). Since June 2005 FFP, FFP and cryoprecipitate for neonatal use (paedipacks) and for children under 16 years have been derived from imported plasma. These components are methylene blue treated as a pathogen reduction measure.

7.4 Administering blood components Identifying the patient and component before transfusion
Particular care should be taken in the identification of neonates. A baby lying in an incubator or cot appears anonymous. For example, the gender of the infant may not be immediately apparent and the identity wrist/ankle band may not carry a first name. Twins and triplets may differ only in their hospital identity numbers. It is particularly important, then, to use the

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unique hospital identity number on the wristband, blood component and accompanying documentation to safely identify the infant. A surrogate marker, such as a name on an incubator, is not an acceptable alternative. Volumes of blood components given to children are generally calculated in terms of mLkg body weight. Typical volumes may be 1020 mL/kg of red cells, 1020 mL/kg of fresh frozen plasma, 10-20 mL/kg platelets and 5 10 mL/kg cryoprecipitate. The transfusion volume and rate of administration must be carefully controlled and it is good practice to use an infusion pump, especially in the neonatal setting. As for adult transfusion, any infusion device used must have been tested and shown by the manufacturers to be suitable for the transfusion of blood components. Syringe drivers are suitable for neonatal transfusion. Whatever kind of device is used, it is important to incorporate a suitable macroaggregate filter. This may be inserted between the bag and the syringe during syringe filling or between the syringe and the IV access device. If no filter is used, it is important to bear in mind that macroaggregates will, instead, be trapped in the patients pulmonary vessels. While there is no clear evidence that this is definitely harmful, it is probably wise to avoid this, especially in infants with pulmonary disease. Blood components can be safely transfused through small gauge peripheral cannulae (e.g., 19 Gauge) or central lines, including umbilical catheters. However, some neonatologists feel that the administration of blood through umbilical catheters (venous or arterial) may increase the risk of developing necrotising enterocolitis. Check your own units policy before using these catheters for the transfusion of blood components.

Case Study 7
Male baby G required a top-up transfusion of group O red cells. Two babies with the same surname were on the neonatal unit. Neither had been given a forename at that time. Group A red cells for female baby G arrived on the neonatal unit. The bedside check was inadequately performed and male baby G received group A red cells intended for female baby G. As a result, male baby G suffered an adverse transfusion reaction and subsequently developed severe cerebral palsy. Baby Gs parents successfully sued their local Health Board. Mrs G summed up her feelings in court by saying: Id like to know who I can blame . . . I still feel hate. I am angry and furious . . that someone couldnt be bothered to treat my child in a safe and professional manner.

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ACTIVITY 28
Identify what factors contributed to the serious incident outlined in Case Study 7. How could this error have been prevented? What procedures should be in place to ensure that the identification procedure for paediatric patients is carried out safely?

7.5

Monitoring the transfused patient

Monitoring children during transfusion is not fundamentally different from adult practice as the same types of adverse reactions can occur. Baseline observations and early checks are just as important and perhaps even more so in children who are unable to report that they are feeling unwell. Restlessness, crying, panic or unexpected lethargy may all be signs of an early transfusion reaction. If there is any doubt, the transfusion must be stopped until the patient can be assessed. Neonates rarely, if ever, develop simple non-haemolytic febrile transfusion reactions. Their temperature may rise or fall in response to a septic event and this type of reaction should be regarded as possibly septic in nature. Episodes of acidosis, hypotension and respiratory compromise have been reported in preterm infants who are reacting adversely to transfusion. The transfusion should be stopped and the IV access kept open with normal saline until the patient can be fully assessed.

Key points

1 Parents or guardians must be involved in the decision to

transfuse their child. 2 Maternal antibodies may be relevant when crossmatching neonates. A blood sample from the mother should be provided at the time of the first crossmatch. 3 Correct identification and monitoring is just as vital in paediatric patients as in adult patients. Particular care must be taken in the identification of neonates who may not have yet been given a first name.

4 Transfusions must be given through an appropriate filter

(170-200 m).

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8
Action Plan
This final section pulls together your work on the activities you have completed as you have worked through this pack. You have probably identified a number of improvements to clinical transfusion procedures that you think could be made in your own clinical area and it is now time to identify priorities and begin putting your ideas into action.

Learning outcomes
When you have completed this section, you should be able to: 1 Reassess your knowledge and skills in relation to the learning outcomes now that you have completed the pack. 2 Review your work on the activities, identifying improvements that you can implement and those that will require action by others. 3 Prepare and implement a realistic Action Plan to introduce changes that will improve the quality and safety of transfusion practice in your clinical area.

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8.1

Reviewing your progress

Before you started work on this pack, you were asked to assess your knowledge and understanding in relation to the learning outcomes for each section. Now that you have reached the end of the pack, use the list of learning outcomes to review the knowledge you have gained and the skills you have developed during your study of safe transfusion practice.

ACTIVITY 29
For each learning outcome (pp. 73-74), tick the box that most closely corresponds to the point you feel you have now reached, again using the scale 14. You should find that your rating has improved in relation to each learning outcome, although you may have found some topics more challenging than others. If there is anything you still dont feel confident about, re-read the appropriate section and then discuss any remaining problems with your local transfusion practitioner/ haemovigilance officer, clinical manager, colleagues or supervisor before continuing with your Action Plan.

8.2

Making an Action Plan

As you have worked through this pack, you have probably identified a number of ways in which the quality and safety of transfusion practice might be improved in your clinical area. Making an Action Plan will provide you with a framework for working towards practical improvements, within any financial, resource or staffing constraints that exist. You may have tried out some of your ideas already, but some will require more time and effort and so it is important to identify priorities. You will almost certainly not be in a position to put all your ideas into action yourself and it may be necessary to convince other members of staff to initiate the actions that you have identified as being both necessary and feasible.

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Section 1 - The Transfusion Process

1 Identify the points at which you are involved in the transfusion process 2 Identify the most common errors in the transfusion process 3 Outline your professional accountability in relation to the transfusion process

Section 2 - Blood Group Serology

1 Understand the importance of blood group systems in the provision of compatible blood 2 Be aware of the options available to the hospital transfusion laboratory for the supply of blood to your patients 3 Communicate this information to patients, relatives and less experienced colleagues

Section 3 - Ordering Blood

1 Inform patients of the expected benefits, risks and outcomes of transfusion 2 Ensure that the blood request form is completed clearly and accurately 3 Correctly label the blood sample tube 4 Communicate effectively with the hospital transfusion laboratory to ensure that the right patient receives the right blood at the right time

Section 4 - Collecting, Delivering & Storing Blood

1 Follow the correct procedures for checking the patients identification details and the traceability label attached to the blood component to ensure that the correct pack is withdrawn from its storage location 2 Document the collection and delivery of blood components and their removal from the ward or theatre refrigerator

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3 State the correct temperature ranges for the storage of blood components 4 Ensure that blood components are kept in the correct storage conditions during transportation and in the clinical area before administration to the patient 5 Follow the correct local procedures for returning unused blood components to the hospital transfusion laboratory

Section 5 - Checking and Administering Blood

1 Explain the importance of meticulous checking of patient identification details, documentation and the blood component at each stage of the transfusion process 2 Correctly undertake the formal patient identity check at the bedside before the transfusion of every unit of blood component in order to prevent the administration of an incompatible blood component to a patient 3 Select and correctly use the appropriate equipment when administering blood components 4 Select and correctly use an appropriate infusion device, when indicated

Section 6 - Monitoring the Transfused Patient

1 Monitor patients appropriately before, during and on completion of a blood transfusion 2 Correctly document each transfusion episode 3 Recognise, and take appropriate initial action in response to a possible transfusion reaction

Section 7 - Paediatric Transfusion

1 Identify the specific requirements of paediatric patients requiring transfusion. 2 State the particular precautions that need to be taken in the identification and monitoring of paediatric patients, particularly neonates and infants.

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ACTIVITY 30
Look back at the suggestions for improvement that you have made as you worked through the activities in the pack. Make a list of those where you have not yet been able to take any action. Then divide them into two categories: Actions you can take Actions that others could take. For each category of action, choose the ones that you think are most important and put them in order of priority. Note them down in the first column of the Action Plan on p. 77. In the second column, briefly summarise the action that you plan to take or that you recommend should be initiated or taken by others. In the third column, note down the outcomes that you would expect. Then show your plan to your local transfusion practitioner/haemovigilance officer, clinical manager and supervisor and discuss it with them. Your proposals may need to be modified as a result of these discussions. Other senior staff may also need to be consulted before your Action Plan can be agreed. When you have reached agreement about planned actions, set dates for their expected completion and note them in the fourth column.

8.3

Implementing your Action Plan

You should now begin to implement your Action Plan along the lines agreed with your clinical manager, supervisor or local transfusion practitioner/haemovigilance officer. It will probably take several weeks or months to put your all plans into action and you may need more time than you expected. You may also find that some of your ideas for improvement are more difficult to implement than you expected and you may need to revise some of your plans if they are too ambitious or are not working as well as you hoped. However, if you have thought carefully about how you could apply what you have learned from this pack and have discussed your ideas with the appropriate people, you should be able to put at least some of them into practice. If you have any problems during this time, talk to your clinical manager or supervisor and ask them for any assistance you need. You should also give them regular reports on progress.

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ACTIVITY 31
Once each action included in your Action Plan has been completed, note down the date in the fifth column and the final outcomes in the last column. Then review the implementation of your Action Plan by comparing the actual outcomes with the results that you expected. Also compare the planned completion dates with the actual completion dates. Discuss the outcomes with your clinical manager and supervisor. Identify any further actions required to ensure the implementation of the improvements you have identified as being necessary. Over the next few months, monitor the effectiveness of any changes you have been able to introduce and be prepared to make any further changes or take any follow-up action needed to ensure that they continue to lead to improved quality and safety in transfusion practice.

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Action plan
Areas for improvement Planned/ recommended action Expected outcomes Planned completion date Actual completion date Actual outcomes

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Activity Answers
Activity 7, p. 26
Group O RhD Negative blood should be supplied for emergency transfusion if the patients blood group is unknown.

Activity 21, p. 50
A total of seven errors were made during the transfusion episode described in Case Study 6. These errors were as follows. Error 1 Error 2 The component and the patients documentation were checked at the nurses station, not the patients bedside. A single nurse put up the transfusion in contravention of this particular hospitals policy that two registered nurses are required to put up and check a transfusion. No final patient identity check was performed at the bedside. The locum wrongly advised the nursing staff not to notify the on-call haematologist that an incorrect blood component had been transfused. Since the transfusion error was not reported, Patient Y did not receive any investigations for a possible ABO incompatible transfusion. The locum incorrectly stated that the patient would not be harmed by the infusion of a small volume of red cells that might have been incompatible. The locum administered the remaining red cells to Patient X rather than returning the pack to the hospital transfusion laboratory.

Error 3 Error 4

Error 5 Error 6

Error 7

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Glossary of Terms
Antigen Antibody A substance capable of inducing the body to form antibodies A substance present in plasma, produced as a result of antigenic stimulation and capable of reacting with the specific antigen that caused its production Infusion set incorporating a mesh filter (170-200 m). for infusion of blood components Centre where donor blood is processed and tested Same ABO and RhD group Standard form bearing details of patient, test / component / product required which accompanies blood sample to the laboratory Not possessing an antigen or antibody that may induce a haemolytic reaction in the recipient (may not be blood group identical) Label bearing patients details and unique number of component which is applied to the blood component by the hospital transfusion laboratory before issue Identified authority for reporting transfusion adverse reactions and events Selection and compatibility assessment of red cell units Fibrinogen-rich component formed by collecting the precipitate that forms in fresh frozen plasma on thawing at 4C FFP is prepared from anticoagulated whole blood or collected by apheresis, and then frozen to -30C Tests to determine ABO and RhD group and screen for atypical red cell antibodies Filtering at the time of production to reduce white cell contamination Disease state complications including diagnosis and

Blood administration set

Blood Centre Blood group identical Blood request form

Compatible

Traceability label

Competent Authority Cross-match Cryoprecipitate

Fresh frozen plasma (FFP)

Group and screen Leucodepletion Morbidity Mortality

The incidence of death in the population in a given group of people

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Platelets: apheresis

Platelets prepared by apheresis (continuous flow separation) from one donor and sufficient for one adult dose Platelets collected from four or more blood donations and pooled in one bag to give an adequate adult dose Any blood component whose principal constituent is red cells Citrated blood donation with almost all the plasma removed and 100 mL in added nutrient solution

Platelets: pooled

Red blood cells (RBCs) Red cells in Optimal Additive Solution (RCCs in OAS)

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References
Barbara J, Flanagan P (1998) Blood transfusion risk: protecting against the unknown. British Medical Journal, 316 (7141): 13856 Blood Safety and Quality Regulations 2005 No. 50 Blood Safety and Quality (Amendment) (No.2) Regulations 2005 No. 2898 British Committee for the Standards in Haematology Blood Transfusion Task Force (2009) (Chairman Norflok, D.) Guideline. On the Administration of Blood Components Available from: http://www.transfusionguidelines.org.uk (Accessed July 2010) Department of Health (1999) Better Blood Transfusion. Health Service Circular 1998/224 (English version); Management Executive Letter (Scottish version) 1999 (9) Department of Health (2002) Better Blood Transfusion Health Services Circular 2002/009 (English version); NHSHDL (2003) 19 (Scottish version); WHC (2202) 137 (Welsh version); HSS (MD) 6/03 (North Ireland version) EC Directive 2002/98/EC, OJ L 33 8.22003, p30-40 Gray A, Buchanan S, McClelland DBL (2003) Quality Improvement Programme: Safe and Effective Transfusion in Scottish Hospitals the role of the transfusion nurse specialist. NHS Quality Improvement Scotland report Gray A, Murphy WG (1993) Patient Attitudes to Blood Transfusion Survey Unpublished report, Scottish National Blood Transfusion Service General Medical Council (1998) Good Medical Practice, London, GMC McClelland DBL (ed.) (2007) The Handbook of Transfusion Medicine (4th edition) London, HMSO Murphy MJ, Pamphilon D (eds) (2001). Practical Transfusion Medicine. Oxford: Blackwell Science Pawson R, Rajan S, Hazelhurst G et al (1999). Hepatitis C lookback programme: a single hospital experience. Transfusion Medicine, 9 (3): 18993 Serious Hazards of Transfusion http://www.shotuk.org/home/ Nursing and Midwifery Council (2008) Standards of conduct, performance and ethics for nurses and midwives NMC, London Nursing Midwifery Council (2008) Standards for Medicines Management London: NMC Williams FG, (1997), Consent for transfusion British Medical Journal, 315: 3808.

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Resources
British Blood Transfusion Society http://www.bbts.org.uk British Committee for Standards in Haematology (BCSH) Guidelines http://www.bcshguidelines.com/ General Medical Council http://www.gmc-uk.org/ Handbook of Transfusion Medicine http://www.transfusionguidelines.org.uk/index.aspx?Publication=HTM Medicines and Healthcare Products Regulatory Agency http://www.mhra.gov.uk/index.htm National Blood Service http://www.blood.co.uk National Haemovigilance Office (NHO) http://www.giveblood.ie/ National Patient safety Agency http://www.npsa.nhs.uk/ NHS Quality Improvement Scotland http://www.nhshealthquality.org/nhsqis/CCC_FirstPage.jsp Nursing and Midwifery Council http://www.nmc-uk.org Scottish Intercollegiate Guidelines Network http://www.sign.ac.uk Scottish National Blood Transfusion Service http://www.scotblood.co.uk Scottish National Blood Transfusion Service Better Blood Transfusion Continuing Education Programme http://www.learnbloodtransfusion.org.uk/ Serious Hazards of Transfusion (SHOT) http://www.shotuk.org/home/

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Recommended Reading
General Medical Council (1998) Good Medical Practice, London, GMC. McClelland DBL (ed.) (2007) The Handbook of Transfusion Medicine (4th edition) London, HMSO. Murphy MJ, Pamphilon D (eds) (2001) Practical Transfusion Medicine. Oxford: Blackwell Science. Nursing and Midwifery Council (2008) Standards of conduct, performance and ethics for nurses and midwives NMC, London Nursing Midwifery Council (2008) Standards for Medicines Management. London: NMC Royal College of Nursing (2004) Right blood, right patient, right time RCN guidance for improving transfusion practice

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