What information should be obtained prior to the transfusion?

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Reflective questions
Strategies for improvement

The history of blood product use, and relevant clinical and product information are documented in the patient’s healthcare record to minimise risks and optimise clinical outcomes.

Reflective questions

How does the health service organisation ensure that a comprehensive history of blood product use, transfusion history, optimising a patient’s own blood and assessing the patient’s bleeding risk are documented in the patient’s healthcare record?

What processes are used to document adverse reactions to blood or blood products in the patient’s healthcare record?

Key tasks

Document comprehensive information, including blood use, transfusion history and transfusion details, before, during and after transfusions
Develop and implement education activities for the workforce responsible for PBM about documenting transfusion of blood or blood products in the patient’s healthcare record, recognising and responding to adverse transfusion reactions, and documenting adverse reactions in the patient’s healthcare record.

Strategies for improvement

A pre-stransfusion bedside checklist that incorporates the ‘Fast Facts’ information about the new blood pack labels.

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The decision to transfuse and the consideration of other blood management strategies, must be based on a thorough clinical assessment of the patient and of that person’s individual needs.

The indication for transfusion or other blood management strategies must be documented in the patient’s healthcare record.

All blood transfusions must have a valid informed consent.

It can be provided by the patient, parent or legal guardian, or follow the emergency medical procedure consent protocols.

A conversation about the reasons for transfusion and expectations of clinical outcomes must take place between the clinician and the patient or guardian.

Any information provided should be in line with the patient or guardian’s literacy level and in a way they can understand.

Consent must be documented in the patient’s medical record and/or on a transfusion-specific consent form in accordance with local health service policy.

Refer to your local health service policy regarding consent processes for blood transfusion, including inability to obtain consent and for patients who refuse.

All elements of the consent process should be aligned to local, State or territory and national requirements.

Always obtain and document consent from your patient.

Check your local institutional guidelines about informed consent.

Always cover the following when acquiring informed consent:

Explain

Cause/likelihood of bleeding or the low blood count (including any uncertainty).

Nature of the proposed transfusion therapy—what is involved.

Benefits expected.

Risks common and rare but serious.

Alternatives, including the risk of doing nothing.

Ask

Is there anything else you would like to know?

Is there anything you do not understand?

Provide

Interpreter for non-English speaking patients.

Written information.

Essentials

Avoid unnecessary and inappropriate transfusions.
Preventable ‘wrong blood into patient’ incidents are nearly always caused by human error and may cause fatal reactions due to ABO incompatibility.
Most mistransfusion incidents are caused by identification errors at the time of pre-transfusion blood sampling, sample handling in the laboratory, collecting the wrong component from the blood bank or transfusion to the patient.
The identity check between patient and blood component is the crucial final opportunity to avoid potentially fatal mistransfusion.
At every stage of the blood administration process the key elements are positive patient identification, excellent communication and good documentation. These can be enhanced by the use of electronic transfusion management systems and barcode technology.
Hospitals should develop local transfusion policies based on national guidelines and ensure all staff involved in the clinical transfusion process are appropriately trained and competency assessed.
Where possible, patients should give ‘valid consent’ for transfusion based on appropriate information and discussion, but signed consent is not a legal requirement.
Non-essential ‘out of hours’ requests for transfusion and overnight administration of blood should be avoided wherever possible because of an increased risk of errors.

Data from the UK Serious Hazards of Transfusion (SHOT) initiative (http://www.shotuk.org) show that around 1 in 13 000 blood units are administered to the wrong patient with occasional fatal outcomes. ‘Wrong blood into patient’ incidents are preventable and nearly always caused by human error. The root cause of most incidents is misidentification at the time of pre-transfusion blood sampling, laboratory testing, collecting the blood component from the blood bank or administration of the transfusion at the bedside. Potentially fatal ABO-incompatible transfusions still occur although improved clinical policies, staff training and introduction of methods to improve identification, resulting from the various Better Blood Transfusion initiatives, has significantly reduced their number over the last decade. Avoiding unnecessary or inappropriate transfusions is an essential starting point for safe transfusion practice.

The British Committee for Standards in Haematology (BCSH) Guideline on the Administration of Blood Components (2009) (https://b-s-h.org.uk) describes the essentials of safe requesting, collection and administration of blood components (summarised in Table 4.1) and should form the basis of local transfusion policies.

The key principles that underpin every stage of the blood administration process are:

Positive patient identification
Good documentation
Excellent communication.

Table 4.1 Safe blood administration (adapted from the BCSH Guideline on Administration of Blood Components, 2009, with permission)

Positive patient identification	Positive patient identification at all stages of the transfusion process is essential. Minimum patient identifiers are: Last name, first name, date of birth, unique identification number. Whenever possible ask patients to state their full name and date of birth. For patients who are unable to identify themselves (paediatric, unconscious, confused or language barrier) seek verification of identity from a parent or carer at the bedside. This must exactly match the information on the identity band (or equivalent). All paperwork relating to the patient must include, and be identical in every detail, to the minimum patient identifiers on the identity band.
Patient information and consent for transfusion	Where possible, patients (and for children, those with parental responsibility) should have the risks, benefits and alternatives to transfusion explained to them in a timely and understandable manner. Standardised patient information, such as national patient information leaflets, should be used wherever possible.
Pre-transfusion documentation	Minimum dataset in patient’s clinical record: Reason for transfusion (clinical and laboratory data). Summary of information provided to patient (benefits, risks, alternatives) and patient consent.
Prescription (authorisation)	The transfusion ‘prescription’ must contain the minimum patient identifiers and specify: Components to be transfused Date of transfusion Volume/number of units to be transfused and the rate or duration of transfusion Special requirements (e.g. irradiated, CMV negative).
Requests for transfusion	Must include: Minimum patient identifiers and gender Diagnosis, any significant co-morbidities and reason for transfusion Component required, volume/number of units and special requirements Time and location of transfusion Name and contact number of requester.
Blood samples for pre-transfusion testing	All patients being sampled must be positively identified. Collection of the blood sample from the patient into the sample tubes and sample labelling must be a continuous, uninterrupted event involving one patient and one trained and competency assessed healthcare worker. Sample tubes must not be pre-labelled. The request form should be signed by the person collecting the sample.
Collection and delivery of blood component to clinical area	Before collection, ensure the patient (and staff) is ready to start transfusion and there is good venous access. Only trained and competent staff should collect blood from transfusion laboratory or satellite refrigerator. Authorised documentation with minimum patient identifiers must be checked against label on blood component. Minimum patient identifiers, date and time of collection and staff member ID must be recorded. Deliver to clinical area without delay.
Administration to patient	The final check must be conducted next to the patient by a trained and competent healthcare professional who also administers the component. All patients being transfused must be positively identified. Minimum patient identifiers on the patient’s identity band must exactly match those on blood component label. All components must be given through a blood administration set (170–200 µm integral mesh filter). Transfusion should be completed within 4 hours of leaving controlled temperature storage.
Monitoring the patient	Patients should be under regular visual observation and, for every unit transfused, minimum monitoring should include: Pre-transfusion pulse (P), blood pressure (BP), temperature (T) and respiratory rate (RR). P, BP and T 15 minutes after start of transfusion – if significant change, check RR as well. If there are any symptoms or signs of a possible reaction – monitor and record P, BP, T and RR and take appropriate action. Post-transfusion P, BP and T – not more than 60 minutes after transfusion completed. Inpatients observed over next 24 hours and outpatients advised to report late symptoms (24-hour access to clinical advice).
Completion of transfusion episode	If further units are prescribed, repeat the administration/identity check with each unit. If no further units are prescribed, remove the blood administration set and ensure all transfusion documentation is completed.