Download policy for the transfusion of blood and blood components

POLICY FOR THE TRANSFUSION OF BLOOD AND
BLOOD COMPONENTS
Document Author
Written By: Transfusion Practitioner /
Transfusion Laboratory Manager
Authorised
Authorised By: Chief Executive
Date: July 2015
Date: 17th November 2015
Lead Director: Clinical Director, Clinical
Support, Cancer and Diagnostic Services
Effective Date: 18th December 2015
Review Date: 17th December 2018
Approval at: Policy Management Group
Date Approved: 17th November 2015
POLICY FOR THE TRANSFUSION OF BLOOD AND BLOOD COMPONENTS
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DOCUMENT HISTORY
(Procedural document version numbering convention will follow the following format. Whole numbers for approved
versions, e.g. 1.0, 2.0, 3.0 etc. With decimals being used to represent the current working draft version, e.g. 1.1, 1.2,
1.3, 1.4 etc. For example, when writing a procedural document for the first time – the initial draft will be version 0.1)
Date of Issue
Version
No.
Date
Approved
19.09.12
10.06.15
4
4.1
19.09.12
07.08.15
4.1
18.08.15
4.2
06.11.15
4.3
17.11.15
5.0
17/11/2015
Director Responsible
for Change
Nature of
Change
Ratification /
Approval
AD Acute Directorate
CD Hospital &
Ambulance
CD Hospital &
Ambulance
CD Hospital &
Ambulance
Draft
Draft
19.09.12
Review
Clinical Director,
Clinical Support,
Cancer and
Diagnostic Services
Clinical Director,
Clinical Support,
Cancer and
Diagnostic Services
Ratification
Clinical
Standards Group
Policy
Management
Group
Clinical
Standards Group
Approval
Approval
Policy
Management
Group
NB This policy relates to the Isle of Wight NHS Trust hereafter referred to as the Trust
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Contents
1
Executive Summary ....................................................................................................... 4
2
Introduction .................................................................................................................... 5
3
Definitions ...................................................................................................................... 5
4
Scope............................................................................................................................. 7
5
Purpose ......................................................................................................................... 7
6
Roles and Responsibilities ............................................................................................. 7
7
Policy detail/Course of Action ....................................................................................... 11
8
Consultation ................................................................................................................. 24
9
Training ........................................................................................................................ 24
10 Monitoring Compliance and Effectiveness .................................................................... 24
11 Links to other Organisational Documents ..................................................................... 25
12 References................................................................................................................... 25
13 Appendices .................................................................................................................. 26
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1
Executive Summary
1.1
The transfusion of blood and blood components is an important, often lifesaving, part
of the treatment of many patients. It is also a procedure that has an element of risk,
with errors potentially leading to the death of or long term damage to a patient who
receives the wrong blood. The Trust therefore attaches the utmost importance to the
correct procedures for the transfusion of blood and blood components
1.2
SHOT (Serious Hazards of Transfusion) data for 2014 have shown that nationally 40
“Wrong Components” were transfused. In 17 of these “patient identification failure” as
a result of incomplete checking was the root cause. This is a fundamental element in
the transfusion process and the point at which a wrong transfusion can be prevented.
There were 10 ABO incompatible red cell transfusions caused by clinical errors in
both collection and administration, or administration alone (SHOT 2014). Additionally
there were 686 errors reported relating to Wrong Blood in Tube (WBIT) which
potentially could have led to Incorrect Blood Component Transfused (ICBT). Such
potentially fatal errors are preventable through consistent good practice, however
audits of practice in transfusion have shown that simple preventative measures such
as the patient wearing a correct ID Band, being asked to confirm their name and date
of birth which is checked against the ID Band prior to procedures and labelling
samples at the bedside are being overlooked.
1.3
Administering the wrong blood type is the most serious outcome of an error during
transfusions. Most of these incidents are due to failure of the final checks carried out at
the patient’s bedside to positively identify the patient and verify the blood product to be
transfused (NPSA 2006). This demonstrates the importance of correct and meticulous
completion of all the steps in the transfusion process, particularly the final checks at
the bedside, and not making any assumptions about the safety of the steps prior to
this.
1.4
It is the shared responsibility of medical, phlebotomy, laboratory, portering and nursing
staff to ensure safe and reliable, prescribing, requesting, collection of samples, testing
and issuing, transporting and administering of components. All parties must be aware
of their roles and responsibilities and adhere to the safe practices outlined in this
policy.
1.5
This policy sets out the local requirements of the Trust based on National and
European Regulations and Guidelines and must be used in conjunction with the
following additional Trust’s policies / Guidelines:








Patient Identification Policy
Maximum Surgical Blood Ordering Schedule (MSBOS)
Special Blood Component Guidelines
Guidelines for the use of Platelets
Guidelines for the use of Fresh Frozen Plasma
Protocol for the Management of Major Haemorrhage and/or Trauma in Adults and
Children
Guidelines for Peripheral Intravenous Cannula Care and Intravenous Drug
Administration
Cannulation & Venepuncture Policy
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
Infection Control Policies
1.6
Compliance with the above policies, protocols and guidelines will decrease the risk of
patient exposure to errors and is an important element of the risk management of
patients in this Trust.
1.7
This policy will be regularly reviewed and updated by the Hospital Transfusion
Committee (User Group).
Significant changes will require ratification by the
appropriate governance committee.
1.8
The policy will be regularly reviewed in the light of current scientific evidence and
opinion.
2
Introduction
2.1
The transfusion of blood and blood components is an important, often lifesaving, part
of the treatment of many patients. It is also a procedure that has an element of risk,
with errors potentially leading to the death of or long term damage to a patient who
receives the wrong blood. To ensure the right patient receives the right blood, strict
checking procedures must be in place at each stage. Administering the wrong blood
type (ABO incompatibility) is the most serious outcome of error during transfusions
(Never Event). Most of these errors are due to the failure of the final identity checks
carried out between the patient (at the patient's side) and the blood component to be
transfused.
2.2
This policy advises all healthcare professionals, who are involved in the transfusion
process, of safe transfusion practice and is the shared responsibility of all staff
involved in the various stages of the Transfusion Process.
2.3
Training is an essential aspect of safe transfusion, which is required for all staff
involved in the Transfusion Process.
2.4
The clinical benefits to the patient being transfused should outweigh the potential risks,
the most important of these being acute haemolytic reactions, transfusion-transmitted
infections and human error (especially at sample collection and labelling of pretransfusion samples). Stringent procedures must be followed to ensure that the correct
blood component is given and that any adverse reactions are dealt with promptly and
efficiently.
3
Definitions

Authorised Health Care Professionals – staff that have completed the “Non
MedicalAuthorisation of Blood Products” course and have been assessed as
competent to authorise blood products.

Blood / Blood Components: Red cells (RBC), Platelets (PLT), Fresh Frozen Plasma
(FFP) and or Cryoprecipitate (CRYO) hereafter referred to as “Components” within this
document.

BSQR – Blood Safety & Quality Regulations (2005): EU Directives - 2002/98/EC and
2004/33/EC have been transposed into UK law through the Blood Safety and Quality
Regulations 2005 (Statutory Instruments 2005/50, 2005/1098 and 2006/2013). The
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regulations came into force on 8 February 2005 and were implemented on 8 November
2005.

DATIX – Trusts electronic incident reporting system.

G & S – Group and Save: A blood sample that has been grouped and screened for
alloantibodies but compatible red blood cells have not been crossmatched. A G&S
sample is valid for seven days provided the patient has not been transfused or had a
sensitising event within the past three months.

HTC – Hospital Transfusion Committee.

HTT – Hospital Transfusion Team

LIMS – Laboratory Information System

MHRA – Medicines and Healthcare products Regulatory Agency. Competent Authority
for blood safety.

NPSA – National Patients Safety Agency (Now part of NHS England)

Never Event - Serious, largely preventable patient safety incident that should not
occur if the available preventative measures have been implemented.

NHSBT – NHS Blood & Transplant

PCC – Prothrombin Complex Concentrate. Concentrated coagulation factors. Dosage
and duration depends on the severity of the condition and on the patient’s clinical
condition together with laboratory results and the location and severity of the
bleeding. Should be administered intravenously at no more than 3 IU per Kg body
weight per minute.

PID – Patient Identifiable Data

Q Pulse –Laboratory electronic incident reporting system.

SABRE – Serious Adverse Blood Reactions & Events – MHRA “Adverse Incident”
reporting system.

SAE – Serious Adverse Event

SAR – Serious Adverse Reaction.

SHOT – Serious Hazards of Transfusion

WBIT – Wrong Blood in tube

XM – Crossmatch: A blood sample that has been grouped and screened for
alloantibodies against which compatible red blood cells have been crossmatched.
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4
Scope
4.1
This policy applies to all healthcare professionals within the Trust who are involved
both directly and indirectly with the transfusion process and will affect the safety and
well being of patients.
5
Purpose
5.1
Due to the high regulatory standards set out in the Blood Safety and Quality
Regulations, 2005 (BSQR’s), monitored by the Medicines and Healthcare products
Regulatory Agency (MHRA) it is paramount that staff are trained adequately and
competency assessed. This policy, based on national guidelines is intended to give
clear instructions on the correct procedures to be followed by all staff members
involved at any stage of the transfusion process to ensure that the right patient
receives the right blood component at the right time.
6
Roles and Responsibilities
6.1
Trust Board is legally responsible under the provisions of the Blood Safety & Quality
Regulations (2005) (BSQR’s) to ensure that there are policies and procedures in place
to manage all transfusion processes.
6.2
Medical staff or other authorised Health Care Professionals are responsible for:

Ensuring they are trained and assessed as competent in the skills they undertake
in relation to the transfusion process.

Evaluating the clinical need for the transfusion of blood / blood components taking
into consideration any alternatives to transfusion and having fully explained the
risks and benefits to the patient including obtaining consent.

Prescribing components, taking into consideration the patients requirements in
respect of the need for any Special Blood Components (see Guidelines for Special
Blood Components) and the recommendations of the Maximum Surgical Blood
Ordering Schedule (MSBOS).

Responding to transfusion laboratory requests for additional samples as required
e.g. to verify patient’s blood group if a historical group is not held on the Laboratory
Information System (LIMS).

Fully documenting the transfusion episode in the patient’s Medical Records and on
the Blood Transfusion Chart including the reason for the request and any special
blood component requirements.

Ensuring that, if the patient is transferred from their care, a full handover to the
receiving medical staff is undertaken, including details of any components already
requested or required.

Requesting components, ensuring that all sample labelling is in accordance with
this Policy. If a “telephone request”, ensure the order number is recorded against
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the transfusion episode in the patient’s Medical Records and on the Blood
Transfusion Chart.

Taking and labelling of blood samples for laboratory testing in accordance with this
Policy.

Management of any suspected Adverse Transfusion Reactions (ATR’s).

Administering components and recording all necessary information on the Blood
Transfusion Chart.

Monitoring patients, including taking observations during transfusion and carrying
out the appropriate actions in the event of adverse transfusion reactions.
6.3
Nursing staff are responsible for:

Ensuring they are trained and assessed as competent in the skills they undertake
in relation to the transfusion process.

Ensuring that the patient is wearing an accurate and legible ID band at all times
during the transfusion process. (See Patient Identification Policy).

Taking and labelling blood samples for laboratory testing in accordance with this
Policy.

Receiving and recording receipt of the component in the Clinical area by either use
of the electronic system or by paper receipt.

Preparing the patient for Transfusion.

Administering components and recording all necessary information on the Blood
Transfusion Chart and by inputting data into the electronic system if in use.

Monitoring patients, including taking observations during transfusion and carrying
out the appropriate actions in the event of adverse transfusion reactions.

Reporting of suspected transfusion reactions or other related incidents, to the
medical staff or other appropriately trained & competent Health Care Professional.

Completing the audit trail by recording the transfusion episode outcome via the
electronic system if in use, or by paper record and returning it to the Blood
Transfusion Laboratory as soon as possible.

Ensuring that transfusion of components is commenced within 30 minutes of
receipt or components are returned to the Blood Transfusion Laboratory within 30
minutes if not required

Informing Blood Transfusion Laboratory staff of any components which have not
been transfused and have been discarded in the clinical area.

Actioning requests from the Transfusion Laboratory in response to any recall
procedure being instigated and responding to any further action required.
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6.4
Phlebotomy staff responsibilities are restricted to:

Ensuring they are trained and assessed as competent in the skills they undertake
in relation to the transfusion process.

Taking and labelling of blood samples for laboratory testing in accordance with the
Trust’s Policy.
6.5
Hospital Blood Transfusion Laboratory staff are responsible for:

Ensuring they are trained and assessed as competent in the skills they undertake
in relation to the transfusion process.

Checking that the labelling of request forms and blood samples comply with this
policy and the Trust’s “Patient Identification Policy”.

Providing an “order number” to a medical officer or other authorised Health Care
Professional who is requesting components via telephone.

Blood grouping, antibody screening and crossmatching of samples. Including any
additional investigations and requesting any additional samples deemed
necessary.

Labelling and issuing blood and blood components.

Traceability, ensuring there is a full audit trail recorded electronically or by a paper
based system.

Investigating and reporting of suspected Serious Adverse Events and Reactions
(SAE & SAR’s), reporting to SHOT / SABRE as necessary.

Initiating/actioning component recall procedures in response to a recall being
initiated externally (e.g. NHSBT) or internally.
6.6
Porterage staff and Hospital Transport Drivers responsibilities are restricted to:

Ensuring they are trained and assessed as competent in the skills they undertake
in relation to the transfusion process.

Collection and delivery of samples and request forms.

Completion of the Blood Collection Slip which must include the patient’s full
name, date of birth and IW number.

Removal of components through the electronic blood tracking system and delivery
to the clinical area in a timely manner, ensuring receipt at the clinical area is
recorded.

Return of components to the Issue Refrigerator or Blood Transfusion Laboratory
via the electronic blood tracking system as soon as possible if necessary.
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6.7
Ward / Departmental Managers and Clinical Leads are responsible for ensuring that
all staff working within their areas:

Have completed training in “Safe Transfusion Practice” by completing the “on-line”
module on a yearly basis.

Are assessed as competent in the skills they use as part of the Transfusion
Process by completing the National Patient Safety Agency (NPSA) Competency
Assessments (available on the Intranet) on a 2 yearly basis or by the completion
of the “on-line” competency assessment on the Trusts’ e-learning module.
6.8
Hospital Transfusion Team (HTT) is responsible for:

Writing and/or reviewing transfusion policies and procedures, ensuing that they
are fit for purpose and referring them to the HTC for approval.

Reviewing the arrangements for training of staff in transfusion policies and
procedures.

Reviewing serious adverse events and reactions, including near misses and
reporting findings to the HTC and externally to SHOT/SABRE as applicable.

Reviewing the appropriateness of blood transfusion and making recommendations
about the proper use of components and reporting findings to the HTC.

Recommending corrective action in transfusion practice, where indicated.

Reviewing new evidence and best practice guidelines around transfusion, the
efficient use of components or alternatives to transfusion and making
recommendations to the HTC.

Providing assurance to the HTC that systems are in place to minimise risk to
patients.

Ensuring that new evidence and practice from national reports and guidance are
implemented.

Providing continued education in transfusion medicine for all relevant members of
staff.
6.9
Hospital Transfusion Committee (HTC) is responsible for:

Reviewing transfusion policies and procedures as referred from the HTT.

Reviewing the arrangements for training of staff in transfusion policies and
procedures.

Reviewing serious adverse events and reactions, including near misses as
referred by the HTT.

Reviewing the appropriateness of blood transfusion and making recommendations
about the proper use of components.

Recommending corrective action in transfusion practice, where indicated.
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
Reviewing new evidence and best practice guidelines referred by the HTT around
transfusion, the efficient use of components or alternatives to transfusion and
making recommendations for implementation.

Ensuring that recommendations, based on new evidence and practice, from
national reports and guidance are implemented

Providing assurance to the Trust Board that systems are in place to minimise risk
to patients.

Promoting continued education in transfusion medicine for all relevant members of
staff.
.
7
Policy detail/Course of Action
7.1
Collection and Labelling of Blood Samples for Pre Transfusion Testing.
7.1.1 Request Form

Request forms MUST be clearly completed in legible handwriting. Addressograph
labels may be used on the request forms only and MUST be attached to ALL
copies of any multi-part forms. Addressograph labels MUST be clear and without
alteration. The form MUST be signed by the requesting medical officer or other
authorised Health Care Professional.

Requests for “Group & Save” MUST be made on a Blood Sciences request form.

Requests for Crossmatched red cells MUST be made on the “Blood Transfusion
Crossmatch Request” form unless a telephone request is made.
7.1.2 Samples
Samples MUST be collected and labelled as one uninterrupted process involving one
member of staff and one patient. One patient must be completed before commencing
any further patients

The staff member collecting the sample MUST ensure that they have positively
identified the patient immediately prior to collection by the use of ‘open’
questioning i.e. by asking the patient to state their full name and date of birth

Identification details provided by the patient MUST be checked / confirmed against
the patient’s ID band and request form (it is acceptable to confirm by
documentation only in an outpatient setting).

Children, patients suffering from dementia or the unconscious or sedated must be
identified by the information on their ID band only. Refer to The Trust’s “Policy for
Patient Identification”.

Sample labelling must be completed by the staff member taking the sample.
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
The sample label must be completed immediately after collection, not remotely or
prior to the procedure.

All samples MUST be completed accurately in legible handwriting without
alteration using indelible ink or by using a label produced by the electronic blood
tracking system which uses the patient’s ID band barcode the together with the
staff members identification barcode.
o
A staff identification barcode MUST ONLY be used by the person it
was issued to
o
NO other Addressograph or
acceptable on samples
electronically printed labels are

The Blood Transfusion Laboratory cannot accept inadequately or
inaccurately labelled samples. (See Organisation’s Patient Identification
Policy).

The minimal acceptable labelling requirements on samples are:
o
Surname
o
Forename (for unnamed infants use MI or FI).
o
Date of Birth
o
IW number
o
‘U’ Numbers will be issued by ED and ‘Maternity in the event of a
computer failure
o
‘E’ Numbers will be issued in the event of a Major Incident
o
Signature of person taking the sample
o
Date of collection

For emergency admissions of ‘unknown’ patients, the minimal acceptable
labelling requirements are:
o
Surname: “Unknown”
o
Forename: “Female” or “Male”
o
Hospital No: “IW Number” or Unique ‘U’ or ‘E’ Number
o
Signature of person taking the sample
o
Date of collection
7.1.3
Two sample rule

A second sample will be requested by Transfusion Laboratory staff to confirm the
ABO group of any patient requiring blood components who has a current sample
in the laboratory but has no historical group recorded on the LIMS

The second sample MUST be taken independently of the original sample.

In an urgent situation only group O red cells will be issued until the second sample
has been processed
Note: for neonates/children for whom it is not possible to obtain a second sample in an
urgent situation, group specific red cells will be issued after a second group check on the
original sample.
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7.1.4 Timing of sample collection for pre-transfusion testing

To ensure that the blood sample used for crossmatching is representative of a
patient’s current immune status the following timings for sample collection are
required:
Patient Type
o
o
Sample Storage at 2 – 8 C (once tested)
Patient transfused or pregnant in
last 3 months
Patient NOT transfused or NOT pregnant
in last 3 months
Sample valid up to 3 days*
Sample valid Up to 7 days
*This is the time between the sample being taken and the subsequent transfusion
Note:
For routine crossmatches, samples should ideally be taken 5-7 days before the date red
cells are required.
Where the patient has been transfused or pregnant within the preceding three months or
when such information is uncertain or unavailable, a sample should be collected no more
than 48 hours in advance of the actual transfusion. The transfusion should ideally be
completed within 72 hours of sample collection.
7.2
Requesting Blood and Blood Components.

It should be remembered that patients have the right to refuse any
transfusion of components. This should be clearly documented in the
patient’s Medical Records / consent forms. This applies to all patients. (See
guidance relating to Jehovah’s Witnesses).

Non essential and “out of hours” requests for transfusion and overnight
administration of blood components should be avoided wherever possible
because of the increased risk of errors.
7.2.1
Routine Requests (over 24hrs)
Red cells


Requests for transfusions MUST be made by a medical officer or other authorised
Health Care Professional by:
o
Completing the “Blood Transfusion Crossmatch Request” form and
should be made at least 24 hrs in advance of the intended transfusion
o
Contacting the Blood Transfusion Laboratory and making a telephone
request. If a G&S has been taken then a telephone request MUST be
made
For ALL telephone requests, the Blood Transfusion Laboratory staff will give the
requesting medical officer or other authorised Health Care Professional an “order
number” to confirm the request. The requestor MUST write this number in the
patient’s Medical Records and Blood Transfusion Chart together with the reason
for transfusion.
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
All requests for blood components MUST give full patient identification details,
including:
o
Surname
o
Forename
o
o
Date of Birth
IW Number

The full indication for the request MUST be provided including the underlying
cause (or condition) that necessitated the transfusion.

Details of the quantity and type of component required including any special
requirements and the time and date it is required MUST be stated.

The location of the patient at the time of the request MUST be stated together with
the location where the blood components are to be given (if different).

Clinical details, giving information about the patient’s diagnosis should be
provided, wherever possible including any past obstetric and transfusion history.
Other Components (e.g. Platelets (PLT), Fresh Frozen Plasma (FFP), Cryoprecipitate
(CRYO), Prothrombin Complex Concentrate (PCC)

A telephone request MUST be made by a Medical Officer or other authorised
Health Care Professional in the event of other components being required.
7.2.2

7.3
Urgent Requests (Within 24hrs)
If the transfusion is required URGENTLY or within 24 hrs the requesting
practitioner MUST ring the Blood Transfusion Laboratory and make a
Telephone Request. (See the Trust’s Major Haemorrhage protocol)
Consent for Transfusion

It is the sole responsibility of Medical Staff or other authorised Health Care
Professional to obtain a “valid consent” for the transfusion. As with any emergency
treatment, the need for consent must not prevent or delay essential urgent
transfusion, but the presence of a valid Advance Decision Document declining
transfusion should always be respected.

The patient MUST be fully informed of the risks, concerns and any alternative
therapies. This information MUST be recorded on the Blood Transfusion Chart
and in the patient’s Medical Records. Leaflets “Will I need a Blood Transfusion /
Platelets” are available from the Transfusion Practitioner or via the Intranet.

Patients transfused when it is not possible to obtain consent prior to transfusion
should be provided with information retrospectively. This is important as
transfused patients are no longer eligible to act as blood donors. For the same
reason, patients who have given consent for possible transfusion during surgery
should be informed if they actually received blood while under anaesthesia. A
leaflet “Unexpected Transfusion” is available from the Transfusion Practitioner.
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
Patients needing long-term transfusion support should have a modified form of
consent and consent is not required for each transfusion episode providing
consent has been clearly documented within the past year.

For paediatric patients the parents must give a “valid consent” to the transfusion
and should be fully informed of the risks, concerns and any alternative therapies.
Consent should be clearly documented on the Blood Transfusion Chart and within
the patient’s Medical Records. A leaflet “A Parent’s Guide to Transfusion” is
available from the Transfusion Practitioner.
7.4
Prescription of Components

It is the sole responsibility of Medical Staff or other authorised Health Care
Professional to prescribe blood or blood components.

It is essential that all the following patient identification details be recorded on the
Blood Transfusion Chart:
o
Surname
o
Forename
o
Date of Birth
o
IW Number

The indication for the transfusion MUST be documented in both the patient’s
Medical Records and on the Blood Transfusion Chart. The prescription must
specify:
o
The type of component to be administered, including any special
requirements e.g. Irradiated, CMV negative, Emergency O Negative
Blood or “Other” i.e. washed cells etc (See Guidelines for Special
Blood Requirements)
o Number of Units / Quantity to be given
o Duration of transfusion. (Up to maximum permitted time)
7.5
o
Any special instructions, e.g. any medication required before or during
the transfusion
o
Wherever possible, routine transfusions should not be carried out
at night where reduced Nursing Staff and/or reduced lighting may
contribute to a Transfusion Reaction being missed. Where the
patient’s condition clinically indicates a transfusion overnight, care
must be taken that the patient is strictly monitored to ensure that a
Transfusion Reaction is noted immediately. When the decision to
transfuse is made, it is imperative that the prescriber considers all risks
to the patient and that any steps to reduce that risk must be taken.
Collection and Delivery of Components
7.5.1 Only staff trained and assessed as competent in using the electronic blood
track kiosk are permitted to access the Issue Fridge. Access is controlled by
use of individualised bar-coded ID cards. Under no circumstances must ID
cards be lent / borrowed between staff or given to untrained staff.
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7.5.2 Only components for ONE patient MUST be removed from the Issue Fridge at
a time. Collecting components for more than one patient at the same time is
NOT PERMITTED
7.5.3 The person collecting the blood MUST have documentation specifying the
patient identification details, which MUST be checked against the patient
identification displayed by the electronic blood track kiosk This will be one of
the following:




Patient’s Medical Records
Blood Transfusion Report
Blood Transfusion Chart
Blood Collection Slip (This may be relayed by telephone message)
7.5.4 The following details MUST match:




Surname
Forename
Date of Birth
IW Number
7.5.5 All components MUST be removed by scanning the component unit number
via the electronic blood track kiosk. IT IS NOT PERMISSABLE for ANY
component to be removed from the Issue Room without first scanning through
the kiosk unless otherwise instructed by Laboratory Staff.
7.5.6 It is important that the compatibility label is date / time stamped prior to
removing the component from the Blood Issue Room unless electronic blood
tracking compatibility labels are in use.
7.5.7 Red blood cells (RBC’S) MUST be stored in a designated, purpose built Blood
Transfusion Laboratory Refrigerator at 4oC. Under no circumstances MUST
they be placed in a domestic refrigerator.

Single red cell units should be transported in a red “Blood Component
Transit Bag”. Once removed from the Blood Issue Fridge, collected
units must be delivered directly to the clinical area. If red cells have
been received in the clinical area but a decision made not to transfuse
for any reason they MUST be returned to the Issue fridge WITHIN 30
minutes of removal.

Multiple units of red cells MUST be transported in a sealed cold box.
Sealed cold boxes are validated for 4 hours. Cold Boxes MUST be
packed in accordance with the instructions in the Blood Issue Room.
Once packed and sealed, the cold box MUST be delivered directly to
the clinical area and if not required MUST be returned unopened to the
Issue fridge WITHIN four hours of removal.
Red cells issued in a sealed cold box MUST be transfused or returned
within the 4 hour period. Once sealed, the box should not be opened
unless required. Once opened, the cold chain has been broken and
the red cells must be transfused within 4 hours or returned to the Issue
Fridge within 30 minutes.
Red cells for delivery to another hospital MUST be sealed in a cold
box and not be opened unless required. Requesting medical officers


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MUST inform the Blood Transfusion Laboratory of the intention to
transfer Blood Components to another hospital BEFORE removal from
the Issue Fridge.
7.5.8 Platelets (PLTS) MUST NOT be refrigerated; they MUST be stored in a
Platelet Incubator at 22oC and should be transported in a Blood Component
Transit Bag.
7.5.9 Fresh Frozen Plasma (FFP) is stored deep frozen below -25oC. Once thawed,
should be transported at ambient temperature in a Blood Component Transit
Bag. Multiple units of FFP for the same patient may be carried in the same
transit bag.
7.5.10 Cryoprecipitate (CRYO) is stored deep frozen below -25oC. Once thawed,
MUST be transported at ambient temperature in a Blood Component Transit
Bag and MUST NOT be refrigerated once thawed. Multiple units of CRYO for
the same patient may be carried in the same transit bag.
7.6
Receipt of Components
7.6.1 If the components are in a sealed cold box, the box should NOT be opened
and the packing label receipted with the date and time of arrival. Otherwise on
arrival in the clinical area, a trained member of staff (medical practitioner,
registered nurse, operating department practitioner/ assistant) MUST examine
the unit and check:

The component details correspond with the Compatibility Label attached to
the component. This will carry the following information:
o
Donor unit number and group
o
Surname
o
Forename(s)
o
IW Number
o
Date of Birth
o
Patients Blood Group

The Compatibility label MUST be completed with the time & date of arrival in
the clinical area, together with the receiver’s signature.

If in use, the electronic tracking system should be used to receipt the unit on
the clinical area by scanning the barcode on the electronic Compatibility Label
together with the identification barcode of the member of staff.

Full Patient Identification e.g.
o
Surname
o
Forename
o
Date of Birth
o
IW Number (NOT case note Number or NHS Number)
o
Correct Blood Group
o
Expiry date of unit
o
Integrity of the pack
o
Any unusual colour, turbidity (sediment or particles), or clumping of the
contents
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7.7

The Compatibility Label MUST remain attached to the component throughout
the transfusion.

Transfusion of components should commence within 30 minutes of receipt in
the clinical area.

If red cells have been received in the clinical area but transfusion not started
within 30 minutes of receipt and the component is subsequently required for
transfusion the unit MAY remain on the ward but MUST be transfused within
3.5 hours (e.g. 30 minutes + 3.5 hours = Total 4 hours).
Return of Blood Components
7.7.1 If the transfusion of components cannot be commenced within 30 minutes the
unit should be returned to the Issue Fridge by trained staff and scanned
through the electronic tracking system. If the electronic system “alerts” then
Blood Transfusion Laboratory staff MUST be informed and the component
handed to them.
7.8
Preparation of the Patient
7.8.1 If possible the procedure MUST be explained to the patient and consent
obtained. The NHS information sheet “Receiving a Blood Transfusion” is available
from the Transfusion Practitioner if required.
N.B. Jehovah’s Witnesses will be identified by a RED clasp on the wristband. Ensure
all red wristband clasps are identified as to the reason they are in place and acted on
accordingly.
7.8.2 Prior to requesting collection of components from the Issue Fridge, ensure
adequate venous access is in situ.
7.8.3




Prior to commencing the transfusion, obtain baseline vital signs, including:Temperature
Pulse
Respiration
Blood Pressure
7.8.4 The patient MUST also be questioned about any symptoms such as chills,
itching, rashes, muscle aches or difficulty in breathing prior to the transfusion
commencing as these symptoms may be mistaken for a transfusion reaction.
7.8.5 The patient MUST be able to be observed at all times in a safe clinical
environment and made as comfortable as possible.
7.8.6 Pre-medication of the patient may be required in certain circumstances which
will be identified by the clinicians.
7.9
Pre-Infusion Checks.
7.9.1 There MUST be a fully completed Blood Transfusion Chart which has been
signed and dated by the medical staff or other authorised Health Care Professional
detailing:
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



7.9.2
The patients, Forename, Surname, Date of Birth and IW Number
The number and type of component to be transfused over a specified time
Any special requirements e.g. CMV Negative / Irradiated Units
Any concomitant drugs / premedication required
Prepare the following equipment:

Sterile blood administration set primed with normal saline 0.9%.

Gloves (non sterile), must be worn when handling blood and blood
components.

If required, a volumetric infusion pump with dedicated giving set which has
been specifically identified as being suitable for blood transfusion by the
manufacturer.

Components MUST be transfused by a separate intravenous route from all
other infusions. No other solutions / drugs MUST be added directly to any
blood component. If a multiple lumen venous catheter is in situ, this may be
used, one lumen must be solely used for blood transfusion.

In exceptional circumstances, where it is not possible to have more than one
intravenous access point and where withholding a drug could be deemed
detrimental, the transfusion should be stopped briefly and a double lumen
needle free device with an anti-reflux valve fitted. This should be flushed prior
to recommencing the transfusion with Normal Saline (Sodium chloride 0.9%).
(Opioid PCA system must be given via a non return valve).

Components MUST be infused through a blood giving set fitted with a 200
micron filter. The giving set MUST be changed:
o
o
o
o
At least 12 hourly
After every 3 components infused
If different ABO groups are given
If different components are given

If IV set requires priming, then ONLY Normal Saline (Sodium chloride 0.9%)
MUST be used.

A blood warmer should be used if a large volume transfusion is given in a
short time e.g. more than 50mL/ Kg / per hour or 1 unit per 10 minutes in an
adult. Blood MUST NOT be warmed by any other means.
7.9.3
Prior to administration, the component MUST be examined, checked and
cross-checked against the Blood Transfusion Chart, Compatibility Label and
the ID Band, for the following:

The Patient MUST be wearing an ID Band with their correct details printed /
written clearly on it.

Full PID check by asking the patient to confirm their name and date of birth
and confirming with the information on the ID Band. Identify any red clasps on
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the ID Band and ensure blood or blood components are not contraindicated.
(see Patient Identification Policy)
7.10

Correct ABO / Rhesus Group.

Expiry date of unit on the NHSBT Component Label. (Unless a specific expiry
time is stated the component expires at 23:59 on the date shown on the pack
label).

Check the component label matches any special requirements (CMV
Negative / Irradiated) which have been requested by the clinician.

Integrity of the pack.

Any unusual colour, turbidity (sediment or particles), or clumping of the
contents.

If there are ANY discrepancies the unit MUST NOT be transfused until the
discrepancy has been resolved and the Blood Transfusion Laboratory staff /
Transfusion Practitioner contacted for advice.

Ensure appropriate care plan is written for the patient.
Blood Administration
Non essential and “out of hours” / overnight administration of blood components
should be avoided wherever possible unless clinically indicated because of the
increased risk of errors.
7.10.1 All checks MUST be performed at the bedside.
7.10.2 Components issued from the Blood Transfusion Laboratory MUST have a
Compatibility Label (see Appendix B1 and / or B2) firmly attached. This MUST carry
the following information:

Donor unit number and group

Surname

Forename(s)

IW Number

Date of Birth

Patients Blood Group
7.10.3 A ‘peel off’ copy of the Compatibility Label (see Appendix B1 and / or B2)
MUST BE fixed to the Blood Transfusion Chart to ensure full traceability.
7.10.4 Identification of components and the recipient MUST be carried out by two
members of staff, one of whom must be a Medical Practitioner, or holding current
registration of the UKCC Professional Register as a Registered Nurse (RGN) /
Midwife (RM) / Sick Children’s Nurse (RSCN), or Operating Department Practitioner /
Assistant and will take responsibility for the checks and sign the Blood Transfusion
Chart.
7.10.5 Positive Identification of the patient MUST be carried out before any
component is transfused as per the Trust’s Patient Identification Policy. Children,
patients suffering from dementia, the unconscious or sedated must be identified by
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the information on their ID Band. The following checks MUST be performed at the
bedside:




Surname.
Forename(s)
IW Number
Date of Birth
7.10.6 Positive identification of the patient must be checked wherever possible, by
asking the patient to state their:

Full Name (i.e. Surname and Forenames)

Date of Birth
This MUST be checked and found to be identical with:
Patient’s ID Band

Blood Transfusion Chart

Compatibility Label
If there is any discrepancy with the PID it MUST be investigated before the
transfusion is commenced.
7.10.7 The component label and Compatibility Label (Appendix B1 and B2) must
be checked to ensure that the expiry date and the reservation date of the unit are
valid. The expiry of the unit is at 23:59 on the date shown and the transfusion MUST
be concluded by this time.
7.10.8 The blood group of the component MUST be compatible with that of the
patient as indicated on the Compatibility Label. If this is not the case, then the reason
for the blood group difference will have been communicated. If no communication
has been received then the discrepancy MUST be checked with the Blood
Transfusion Laboratory before the transfusion is commenced.
7.10.9 The donor number on the component label must correspond to that on the
Compatibility Label (Appendix B1 and B2). If any discrepancy is found, advice MUST
be sought from the Blood Transfusion Laboratory staff / Transfusion Practitioner as to
what action should be taken.
7.10.10 Ensure the chosen IV cannula is patent or, if necessary take appropriate
action to ensure patency. If there is going to be a significant delay Components
MUST be returned to the Blood Transfusion Laboratory without delay.
7.10.11 Connect blood administration set fitted with a 200micron filter to intravenous
cannula, secure as appropriate.
7.10.12 Commence the transfusion at the rate prescribed by the Medical Officer or
other authorised Health Care Professional on the Blood Transfusion Chart.
7.10.13 The date and time of commencement MUST be documented on the Blood
Transfusion Chart.
7.10.14 Maintain a full fluid chart and accurately record urine output.
7.10.15 Closely monitor the patient (see Observation of Patient).
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7.10.16 Immediately AFTER the transfusion is commenced the ‘peel off’ label on the
“Compatibility Label” MUST be fixed to the Patient’s Blood Transfusion Chart.
7.10.17 Transfusion of each unit of red cells should normally completed within twothree hours of removal from the Issue Fridge or Cold Box, but no longer than
maximum of four hours.
7.10.18 Platelets should be infused over 30 minutes and as soon as possible after
removal from the Blood Issue Room.
7.10.19 FFP should be infused over 30 minutes and within four hours of removal from
the Issue Fridge. If the FFP is kept in the Issue Fridge then it can be used up to 24
hours after thawing.
7.10.20 CRYO should be infused over 30 minutes and within four hours of thawing.
7.11
Observation of Patients Receiving Blood Transfusion
7.11.1 For each component given, the following observations must be monitored and
recorded on the patients Observation chart (and additionally by entering onto
electronic blood tracking software via the handset).

Immediately prior to transfusion: Temperature, B/P, Pulse &
Respirations (Base Line)

After 15 minutes: Temperature, B/P, Pulse & Respirations

After 30 minutes: Temperature, B/P, Pulse & Respirations

Then hourly (if stable): Temperature, B/P, Pulse & Respirations
7.11.2 The patient MUST continue to be monitored for 24 hours after the transfusion
every four hours. If the patient is a “Day Case” then the patient MUST be given
advice as to what to be aware of and they MUST be given a contact telephone
number where they can obtain advice if they feel unwell after returning home.
7.11.3 Any change in the observations or if the patient develops pain at drip site,
chest pain, back pain, loin pain or a feeling of impending doom etc, must be reported
immediately to medical staff. In any case of suspected transfusion reactions, the
transfusion must be immediately stopped, medical staff informed and appropriate
action initiated.
7.11.4 Refer to Action to Be Taken in All Cases of a Suspected Transfusion
Reaction which appears on the last page of the Blood Transfusion Chart and is also
available on the Intranet.
7.12
Completion of Transfusion
7.12.1 On completion of the transfusion, the “fate” of the component MUST be
recorded on compatibility label which should be returned to the Blood Transfusion
Laboratory as soon as possible (unless the electronic tracking system is in use and
the handset used).
7.12.2 The giving set should be removed and the intravenous cannula flushed with
prescribed normal saline.
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7.12.3 Equipment MUST be disposed of safely in accordance with the control of
Infection policy (see IPC Safe Handling and Disposal of Sharps). The whole giving
set should be discarded in the sharps bin.
7.12.4 Empty component packs should be sealed with a spigot, placed in a leakproof
plastic bag, and disposed as clinical waste by the ward staff.
7.12.5 Partly used components should not have the giving set removed. They must
be placed in a leak-proof plastic container and disposed of as clinical waste by the
ward staff.
7.12.6 If a moderate or severe transfusion reaction is suspected, the component
pack and giving set will be required for further investigation. The pack must be
sealed with a sterile spigot to maintain sterility and returned to the Blood Transfusion
Laboratory immediately in a leak-proof plastic container. This should be sent with a
completed Blood Transfusion Reaction Form and appropriate samples as indicated,
and should be sealed in a separate plastic bag.
7.13
Recall
7.13.1 On occasions there may be the requirement for the recall of red cells,
platelets, FFP or CRYO. This may be at the request of NHS Blood & Transplant
(NHSBT) or internally by the Blood Transfusion Laboratory in response to further
information pertaining to the patient coming to light e.g. special requirements or if an
error/ incident is discovered.
7.13.2 When a recall is indicated it is important that any components that have been
produced from that donation are located as soon as possible and that any
components not transfused are removed from use. If the component has been
transfused then the recipient involved must be identified and appropriate action
taken.
7.13.3 In the event of a recall being instigated the Transfusion Laboratory staff will
follow the laboratory recall procedure
7.13.4 If the component is in a clinical area or “in transit”, the Transfusion Laboratory
will contact the clinical area and request the immediate return of the unit which MUST
NOT be transfused and MUST returned to the Transfusion Laboratory immediately
and handed to a member of the Transfusion Laboratory staff.
7.13.5 If the component is being transfused the transfusion MUST be stopped
immediately and taken down. The unit should be sealed with a sterile spigot, returned
to the Blood Transfusion Laboratory in a leak proof container and handed to a
member of Blood Transfusion Laboratory staff. The episode MUST be recorded on
the Blood Transfusion Chart as “Part Transfusion” together with the amount
transfused and annotated “product recall”.
7.13.6 If the unit has been transfused in whole or in part, the Transfusion Laboratory
will inform the Consultant Haematologist to decide any further action. The clinical
area will be informed of any action that needs to be taken. The episode MUST be
recorded in the patient’s notes and the Blood Transfusion chart relating to the
episode MUST be annotated as Product Recall.
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8 Consultation
8.1 This document is endorsed by the Hospital Transfusion Team and Hospital Transfusion
Committee.
9
Training
9.1 This (Policy for the Transfusion of Blood & Blood Components) has a mandatory training
requirement which is detailed in the Trusts mandatory training matrix and is reviewed on a
yearly basis
10 Monitoring Compliance and Effectiveness
10.1
Monitoring of the policy is carried out as part of the timed planned programme of
audits to ensure compliance.
10.2
The Transfusion Laboratory Manager/ Blood Sciences Quality Manager is
responsible for ensuring internal audits are carried out against ISO 15189:2012 /
MHRA standards that monitor the transfusion process.
10.3
The Transfusion Practitioner is responsible for conducting National Comparative
audits and internal audits in Clinical areas against compliance with the policy.
10.4
All adverse clinical incidents /non-conformances are recorded:


Internally: Q Pulse / Datix
Externally: SHOT (Serious Hazards of Transfusion) / SABRE (MHRA)
10.5
All adverse clinical incidents /non-conformances are fully investigated, the outcome
recorded and Corrective and Preventative Action (CAPA) put in place
10.6
The HTT is responsible for reviewing serious adverse events and reactions, including
near misses and reporting findings to the HTC.
10.7
The HTC is responsible for reviewing serious adverse events and reactions, including
near misses as referred by the HTT and reporting to the Trust board.
10.8
The Transfusion Practitioner is responsible for monitoring the electronic blood
tracking system to identify operator errors in the transfusion process in Clinical areas,
to investigate any errors and put effective CAPA in place.
10.9
The Training & Development Department is responsible for maintaining records of
any Safe Transfusion Practice training carried out as part of the Trust’s Mandatory
Training programme.
10.10 Ward / Clinical Department managers are responsible for recording and maintaining
records of staff within their area in regard to attendance of Safe Transfusion Practice
Training and NPSA Competency Assessments.
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11 Links to other Organisational Documents

Aseptic Non Touch Technique (ANTT Policy)
http://nww.iow.nhs.uk/guidelines/IPC_Aseptic%20Non%20Touch%20Technique%20_ANTT_%20poli
cy.pdf

Maximum Surgical Blood Ordering Schedule

Patient
Identification
http://nww.iow.nhs.uk/guidelines/Patient%20Identification%20policy.pdf
Policy

Safe Handling and Disposal of Sharps
http://nww.iow.nhs.uk/guidelines/IPC_Safe%20Handling%20%20Disposal%20of%20Sharps%20Polic
y.pdf

Training Tracker:

Blood Transfusion Safe Transfusion Practice Level 1 (Mandatory for all Clinical Staff)

Blood Transfusion – Level 2: Modules 1, 2 & 3)

B. Braun Infusomat Infusion Pump (Blood Use Only)

Consent Process - An Introduction
12 References
Association of Anaesthetists of Great Britain and Ireland. 2008. Blood Transfusion and the
Anaesthetist; Red Cell Transfusion 2.
British Committee for Standards in Haematology; Guidelines for the Administration of Blood
Components. December 2009
British Committee for Standards in Haematology; Guidelines for pre-transfusion
Compatibility in Blood Transfusion Laboratories.
Transfusion Medicine, 2012, 23, 1,
British Committee for Standards in Haematology: Guidelines for the Clinical Use of Red Cell
Transfusions. British Journal of Haematology, 2001 113 24 – 31
British Committee for Standards in Haematology: Guidelines for the use of fresh frozen
plasma, Cryoprecipitate and Cryosupernatant. British Journal of Haematology 2004,
Vol126 1
British Committee for Standards in Haematology: Amendment to the guidelines for the use
of fresh frozen plasma, Cryoprecipitate and Cryosupernatant (selection according to
ABO and RhD grouping.) 2005 BCSH Transfusion Task Force.
British Committee for Standards in Haematology: Guidelines for the Use of Platelet
Transfusions. British Journal of Haematology, 2003 122, 1
EU Commission Directives 2002/98/EC, 2004/33/EC, 2005/61/EC and 2005/62/EC (Blood
Safety and Quality Regulations)
POLICY FOR THE TRANSFUSION OF BLOOD AND BLOOD COMPONENTS
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Norfolk D. 2007 “Handbook of Transfusion Medicine” 5th Ed. UK Blood Services London
TSO
The Blood Safety and Quality Regulations. Statutory Instrument 2005 No. 50 and addition
amendments.
13
Appendices
Appendix A
NHSBT Label
Appendix B1 Blood Compatibility Label
Appendix B2 Electronic Blood Compatibility Label
Appendix C
Requesting Components in an Urgent Situation
Appendix D
Investigations of Moderate or Severe Acute Transfusion Reactions
Appendix E
Guidelines – Jehovah’s Witnesses & Blood Transfusion
Appendix F
Blood Transfusion Crossmatch Request Form
Appendix G
Blood Collection Slip
Appendix H
Financial and Resourcing Impact Assessment on Policy Implementation
Appendix I
Equality Impact Assessment (EIA) Screening Tool
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Appendix A
NHSBT Label
Donation Number
ABO / RhD Group
Product Code
Irradiated Product Label
– Only present if product
irradiated when indicator
turns black
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Expiry Date
Additional
Information
e.g. CMV status
etc
Page 27 of 44
Appendix B1
Blood Compatibility Label
THIS LABEL IS ATTACHED TO THE BLOOD OR BLOOD COMPONENT PACK
STOP! Before transfusion read
IT IS A LEGAL REQUIREMENT TO
CONFIRM THE FATE OF THIS UNIT
Group
Unit No.
Product
Surname
Forenames
IW Hosp No
DOB
Ward
Reserved until 9am
Group
Patients
I confirm that the above unit
was:
Transfused (all or part) to the
above named patient
Returned to the laboratory out of
temperature control
Disposed as pack
damaged
Print Name ………………………………………………….
Signature …………………………………………………….
Date ………………………… Time …………………………
S
U
I
T
A
B
L
E
F
O
R
P
A
T
I
E
N
T
Group
Product
Surname
Forenames
IW Hosp No
DOB
Ward
Reserved until 9am
Group
Unit No.
Patients
Group
Product
Surname
Forenames
IW Hosp No
DOB
Ward
Isle of Wight NHS Primary Care Trust
St Mary’s Hospital
Unit No.
the information on the reverse
Reserved until 9am
Patients Group
This tear off
portion is to be
fully completed
and returned to
the Blood
Transfusion
Laboratory as
soon as possible
This “Peel Off”
Sticker is to be
affixed to the
Blood
Transfusion
Chart
Attach this peal off label to the Blood Transfusion Chart
Before Transfusion
Carry out these checks
•
•
•
•
•
•
Ask the patient to state their name and date of birth.
Check these details and the patients hospital number
match the wristband and this label attached to the
unit.
Isle of Wight NHS Primary Care Trust
St Mary’s Hospital
BLOOD SAFETY & QUALITY
REGULATIONS 2005
This information must match the patients wristband
No wristband
No Transfusion
Check the unit numbers is the same on the unit and
this label.
If any details do not match, contact the Blood
Transfusion Laboratory
Do Not Transfuse
If a transfusion reaction is suspected
•
•
•
STOP the transfusion
Seek medical advice
Contact the Blood Transfusion
Laboratory
IMPORTANT
It is a legal requirement to
complete the tear off
section overleaf and return
it to the Blood Transfusion
Laboratory
For Laboratory use only
Fate of unit entered on Laboratory
computer
Incident form completed for this unit
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Appendix B2
Electronic Blood Compatibility Label
THIS LABEL IS ATTACHED TO THE BLOOD OR BLOOD COMPONENT PACK
2D Barcode
Label
This “Peel Off”
Sticker is to be
affixed to the
Blood
Transfusion
Chart
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Appendix C
Requesting Components in an Urgent Situation
Action Plan

The Medical Officer should assess the degree of urgency and decide the type and
quantity of components required or if the Major Haemorrhage Protocol should be
invoked. (Refer to Protocol for the Management of Major Haemorrhage and / or
Trauma in Adults and Children for further guidance).

Request components by direct communication with the Blood Transfusion Laboratory
(Ext. 4800) or Biomedical Scientist (BMS) for Transfusion via bleep indicating:
o
o
o
o
o
Reason for transfusion
Patients Forename, Surname, Date of Birth & IW Number (or Unknown “male
/ female” and “U” or “E” number as appropriate)
Type and quantity of components required
Urgency of request
Location of the patient

If a G&S is held by the Blood Transfusion Laboratory then a telephone request can
be made by a Medical Officer or other authorised Health Care Professional.

For ALL telephoned requests, the Blood Transfusion Laboratory staff will provide an
“order number” to confirm the request. The Medical Officer or other authorised Health
Care Professional MUST write this number in the patient’s medical records alongside
the reason for the transfusion.

Any blood samples MUST be accurately and legibly labelled in accordance with any
samples for G&S / cross matching that are incorrect, incomplete or contain errors in
labelling cannot be accepted and will be discarded

Samples should be sent to the Laboratory using Portering services. The Porters
MUST be contacted by the requesting ward / clinical area, indicating degree of
urgency of the request.

Blood required within:
a. 0 -15 minutes Extreme Emergency – Use of Emergency O RhD Negative
Red cells (maximum four units normally available in the Blood Issue Fridge.
b. 15-30 minutes * - Issue of ABO RhD “Group Specific” blood from receipt of
an appropriately labelled sample in the Blood Transfusion Laboratory.
c. 40+ minutes * - Issue of crossmatch compatible blood from receipt of an
appropriately labelled sample in the Blood Transfusion Laboratory.
d. If a fully tested G&S sample is held in the Blood Transfusion Laboratory,
crossmatched blood can be made available in fifteen minutes unless the patient
has known antibodies then crossmatched blood will be made available as soon
as possible.
e. A second sample will be requested by Transfusion Laboratory staff to confirm
the ABO group of any patient requiring blood components who has a current
sample in the laboratory but has no historical group recorded on the LIMS
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Appendix D
Investigations of Moderate or Severe Acute Transfusion Reactions
*Standard Investigations: Full Blood Count (FBC) Renal & Liver Function Test (U&E / LFT) and Urine Sample for Haematuria
Does the Patient display symptoms of ….
Fever and / or chills, rigors,
myalgia, nausea or vomiting
and / or loin pain?
Hypotension (isolated
fall in systolic blood
pressure of >30 mm Hg
resulting in a level < 80
mm Hg
Dyspnoea, wheeze
or features of
anaphylaxis?
Mucosal swelling
(angioedema)?
Are symptoms
 Standard Investigations*.
Plus investigations as for
fever.
 Inform Blood Transfusion
Laboratory.
 If allergic reaction
suspected measure IgA
Level.
 If severe / anaphalactic
reaction, consider
measurement of serial
mast cell tryptase
(immediate, 3 and 24
hours)
 Contact Consultant
Haematologist for
advice.
TACO
Consider TACO / TRALI
Mild / Isolated
Sustained
Pyrexia ≥ 38oC and rise
< 2oC and / or mild
allergic reaction?
 Continue Transfusion at
slower rate.
 Observe more
frequently.
 Give Paractetamol IV
(500 – 1000 mg in
adults) and / or
antihistamine.




Fever (>2oC rise or >39oC) and /
or chills, rigors, myalgia,
nausea or vomiting and / or
loin pain?
 Did the patient become unwell in
the first few minutes of the
transfusion?
 Are they complaining of flushing,
loin / abdominal pain or”feeling of
“impending doom”?
Consider
Acute Haemolytic Reaction or
Bacterial Contamination of
product.
 Stop Transfusion
 Contact Consultant
Haematologist for advice.
 Standard Investigations*.
 Inform Blood Transfusion
Laboratory.
 Complete Transfusion Reaction
form and take samples for: Repeat compatibility testing,
direct antiglobulin test (DAT)
lactate dehydrogenase (LDH),
haptoglobins, Blood Cultures
from patient and Coagulation
Screen.
 Do Not Discard implicated Unit
and return to Transfusion
Laboratory
Consider
Severe Allergic / Anaphylactic
Reaction.
Standard Investigations*.
Inform Blood Transfusion
Laboratory
Measure IgA level – if <0.07 g/L
in absence of
hypogammaglobulinanaemia )
perfom confirmatory test with
sensitive method and check for
IgA antibodies
Contact Consultant
Haematologist for advice.
TRALI
Patient Characteristics
Implicated Blood Products
Onset
Oxygen Saturation
Blood Pressure
Jugular Blood Pressure
Temperature
Chest X Ray
Echocardiogram
Pulmonary artery wedge
pressure
Blood count
Fluid challenge
Response to diuretics
? More common in haematology /
surgical patients
Usually Plasma or Platelets
Up to 6 hours from transfusion
(usually within 2 hours)
Reduced
Often Low
Normal or Low
Often raised
Bilateral peri-hilar and nodular
shadowing or “white out” heart
size normal
Enlarged heart and
characteristics of
pulmonary oedema
Normal
Abnormal
Normal
Elevated
Fall in neutrophilsand
monocytesfollowed by
neutrophil leucocytosis
Improves
Worsens






Standard Investigations*.
Inform Blood Transfusion Laboratory
Contact Consultant Haematologist for advice.
Check O2 saturation or Blood Gases.
Chest X Ray (Mandatory if symptoms severe)
If severe of moderate allergic reaction suspected,
measure IgA level
 If severe / anaphalactic reaction, consider
measurement of serial mast cell tryptase (immediate,
3 and 24 hours)
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Most common in age >
70 but can occur at any
age
Any
Within 6 hours of
transfusion
Reduced
Often High
Elevated
Normal
No specific changes
Worsens
Improves
Hypotensive reaction
Characterised by an
isolated fall in blood
pressure during or within
an hour of transfusion with
no evidence of allergic
reaction of haemorrhage.
 Stop Transfusion
 Keep flat with legs
elevated.
.
Page 31 of 44
PATIENT EXHIBITING POSSIBLE FEATURES OF AN ACUTE TRANSFUSION REACTION
WHICH MAY INCLUDE: fevers, chills, rigors, tachycardia, hyper- or hypotension, collapse, flushing,
urticaria, pain (bone, muscle, chest, abdominal), respiratory distress, nausea, general malaise
STOP THE TRANSFUSION
Undertake rapid clinical assessment, check patient ID / blood compatibility label / visually assess blood
component.
Is there evidence of life threatening Airway and / or Breathing and / or Circulatory problems and /
or wrong blood given and / or evidence of contaminated unit?
No
Yes

SEVERE / LIFE THREATENING
 Call for Urgent Medical Help – Adult
Emergency (Outreach Team) and
Contact On-Call Consultant
Haematologist for advice.
 Inform Hospital Transfusion Laboratory
(ext 4800 / 4802 or bleep duty BMS for
Transfusion)
 Initiate resuscitation ABC
 Is haemorrhage likely to be causing
hypotension? If not discontinue
transfusion (DO NOT DISCARD
implicated units)
 Maintain venous access.
 Monitor patient e.g. TPR B/P Urinary
2
output, O sats,
 If likely anaphylaxis / severe allergy
follow anaphylaxis pathway.
 If bacterial contamination likely, start
antibiotic treatment.
 Use B/P, Pulse, Urinary Output
(catheterise if necessary) to guide
intravenous physiological saline
administration.
 Complete Adverse Reaction Form and
take appropriate tests as required.
 Return unit (with administration set) to
Transfusion Laboratory.
 Send request form and appropriate
samples to Lab.

 Perform appropriate investigations.


Review at HTC
Report to SHOT/SABRE as appropriate

Sustained
o
Temperature ≥ 39 C
o
or rise ≥ 2 C and / or
Other signs /
symptoms apart from
pruritis / rash only




Consider bacterial
contamination if the
temperature rises as
above and review
patients underlying
condition and
transfusion history.
Monitor patient more
frequently e.g. TPR,
2
BP, O sats, Urinary
output.
Inform Transfusion
Laboratory
Contact Haematologist
for advice.
? Mild Reaction ?


Continue transfusion
Consider symptomatic
treatment
Monitor patient more
frequently as for
moderate reactions
If symptoms / signs
worse, manage as
moderate / severe
reaction (see left)


Are the symptoms consistent with the patients
underlying condition?
No
TRANSFUSION
RELATED


Discontinue (do not
discard implicated units).
Complete Transfusion
Reaction Form as per
guidance.
Perform appropriate
investigations
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Isolated Temperature
o
≥ 38 C and rise <
o
2 C and / or
Pruritis / rash only
Moderate Reaction

Version No.

Yes
Transfusion Unrelated

Continue transfusion
at a slower rate and
provide appropriate
symptomatic treatment
Document in notes that
no HTT / HTC review
SHOT report necessary
Page 32 of 44
ADVERSE TRANSFUSION REACTION
To be completed by the requesting Medical Officer
Patients Details
Surname: ………………………
Forename: …………………………. Date of Birth: ….../….../…… IW Number: …………………
Gender: ………………………
Ward:
………………
Consultant: ………………….
Patient Identification Check
Does the patient identity on the Blood Transfusion Chart, Wristband & Compatibility Label match?
Y / N* (*Circle as appropriate)
Clinical Details - these must be answered fully
Diagnosis: …………………………………………………………………………………………………..
Reason for transfusion: ……………………………………………………………………………………
Previous transfusions (give date of last):.…...………………………
………………….:.…...……………………
Previous known antibodies)
Previous pregnancies (give date of last):.…...………………………………………………
Allergic History: ………………………………………………………………………………………………
Base Line Observations:
Temp:………………. BP: :………………. Pulse:.………………. Resp Rate:………………… O2 Sats: …………
Post Transfusion Observations:
Temp:………………. BP: :………………. Pulse:………………… Resp Rate:………………… O2 Sats: …………
Signs and Symptoms
Rigors Y / N
Rash Y / N
Chest Pain Y / N
Renal Failure Y / N
Anaphylaxis Y / N
Jaundice Y / N
Vomiting Y / N
Haematuria Y / N
Loin Pain Y / N
Wheezing Y / N
Bleeding / Bruising Y / N
Other Symptoms:…………………………………………………………….
Underlying condition(s).
…………………………
Are there any underlying conditions: Sepsis Y / N
Chest Infection Y / N
Other:
Transfusion Information
Blood component transfused: Red Blood Cells / Platelets / Fresh Frozen Plasma / CRYOprecipitate (Circle as appropriate)
Donation Number: ………………………………….… Time / Date transfused: ……………………………..
……………
Volume transfused:
Other components transfused in last 24 hours: ……………………………….………………………………..
Send the following to the laboratory with this form
Blood Sciences request form and the following samples:
MODERATE FEBRILE REACTION
SEVERE Reaction
Three blood group / XM samples (EDTA – pink top)
FBC (EDTA – mauve top)).
Coagulation screen (Citrate – blue top)
LFTs and U/Es (serum SST – gold top)
Microbiology request form and samples for blood culture
Donor unit(s) complete with IV set. SEAL WITH A STERILE SPIGOT
Urine sample
One blood group / crossmatch Sample
(EDTA – pink top
Medical Officer completing this form and requesting investigation.
Name (print): …………………………………….. Signature: …………………… Date / Time
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Appendix E
Guidelines – Jehovah’s Witnesses & Blood Transfusion
(published by Jehovah's Witnesses Hospital Liaison Committee)
General
The Code of Practice of the Royal College of Surgeons of England : Surgical Management
of Jehovah’s Witnesses (2002) together with the Management of Anaesthesia for Jehovah’s
Witnesses published by the Association of Anaesthetists of Great Britain and Ireland, March
1999 are approved by the Organisation and Commended to Medical Staff.
All patients who are Jehovah’s Witnesses should receive full clinical information on any
procedure prior to completion of the consent form. The Hospital Transfusion Team should
be contacted as soon as possible following initial contact with the patient. The patient’s
details and proposed treatment should be disclosed.
Adult Jehovah’s Witness patients (aged 18 and over) will carry an Advance Decision
Document (Also known as and Advanced Medical Directive) indicating their refusal to accept
Blood Transfusion. This could also indicate which other blood or fractionated products or
procedures such as cell salvage they may be willing to accept or refuse, and a copy of this
directive should be placed in the patient’ health care records.
NB. In the case of an unconscious patient where no Advance Decision Document is
available, and who is alleged to be a Jehovah’s Witness, it may be possible to locate a copy
of the Advance Decision Document by contacting the person’s GP, or by contacting a
member of the local Hospital Liaison Committee for Jehovah’s Witnesses. Jehovah’s
Witnesses are encouraged to lodge a copy of their ADD with the Secretary of their local
congregation and with their GP. Where it is not possible to ascertain the patient’s wishes
the presumption should be to preserve life.
It is essential to establish the views held by individuals as certain forms of blood salvage
techniques and the use of fractionated and clotting factors are acceptable to some but not
others. Documentation of this discussion should be made in the patient’s health care record
and the treating healthcare team made aware. Minors, (under 16 years of age), may be
made a subject of a “Specific Issue Order”, often referred to as a Court Order which would
be obtained by the Organizations’ Solicitors, if parental refusal threatens life. In such cases,
the parents should be kept informed and should be invited to any case conference.
The Hospital Liaison Committee (HLC) for Jehovah’s Witnesses may be contacted for
advice. Consent for Staff to share relevant medical records and details of the patient’s
condition with HLC members is expressly given in the ADD.
Patient Autonomy
Patients have a right to receive balanced information concerning proposed treatments
following which they can freely give or withhold consent. Before signing a consent form, the
Jehovah’s Witness should
1. Receive information concerning proposed treatments from the responsible
clinician.
2. Be allowed time to consider the information.
3. Have questions fully answered to their satisfaction.
All discussions should be carried out in the presence of a witness and be recorded and the
record signed by the medical practitioner and witness in the patient’s notes.
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Any exclusion such as declining blood transfusion should be specified on the consent form.
The details recorded on the consent form and agreed between the patient and the health
professional are confidential and cannot be revealed to other persons without the patient’s
consent. In cases where there is considered to be a need for a blood transfusion, and where
there is a declining of blood transfusion constituting a risk to the patient’s life, the medical
practitioner should be satisfied that the patient
1.
2.
3.
4.
5.
6.
Is competent to give or withhold consent.
Has received and understood the relevant information.
Is making a free decision.
Understands the significance of declining blood transfusion.
States what, if any, of the available alternatives are acceptable.
Has completed an Advance Decision Document citing their declining of blood
transfusion and stating their choices of blood derivatives.
The clinician should record in the patient’s notes whether or not the above conditions apply.
Declining should be reaffirmed for each proposed treatment. Declining of blood transfusion
for a past treatment should not be presumed to indicate refusal to accept blood for the
current treatment.
UNACCEPTABLE for Jehovah’s Witnesses
These products are universally rejected by Jehovah’s Witnesses:
1.
2.
3.
4.
5.
6.
Whole Blood
Red cells
White Cells
Platelets
Plasma
Pre-operative Autologous Donation (PAD)
PERSONAL CHOICE for Jehovah’s Witnesses
Some Jehovah’s witnesses may accept these products and treatments, others may reject
them:
1.
2.
3.
4.
5.
6.
7.
8.
Immunoglobulins (e.g. Anti-D)
Albumin
Cryoprecipitate
Fractionated Products (e.g. factor VIII etc.)
HBOCs - Hemoglobin based oxygen carriers (e.g. Haemopure)
Intra or Post operative Cell Salvage
Acute Normovolaemic Haemodilution (ANH)
Haemostatic agents that are based on blood products (adhesives, swabs,
fibrin sealers)
9. Organ Transplants
ALTERNATIVE OPTIONS for Jehovah’s Witnesses
There are many alternatives that may be appropriate. There would be no religious reason
why one of Jehovah’s Witnesses would reject any of these alternatives.
1. Crystalloids (e.g. Normal Saline 0.9%, Hartmann’s solution, 5% Dextrose,
Dextrose/ Saline, Bicarbonate 8.4%, lactated Ringers solution)
2. Colloids (e.g. Haemaccel, Gelofusine, Hetastarch, Pentastarch
3. NovoSeven (recombinant factor VIIa)
4. IV iron dextran (e.g. Cosmofer)
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5. IV iron sucrose (e.g. Venofer)
6. Other haemanitics (folic acid, vitamin B12
7. Erythropoietin (EPO) should be used in conjunction with IV iron.
8. Desmopressin (may be used to boost factor VIII concentration)
9. Vaspressin
10. Antifibrinolytics such as tranexamic acid
11. Hyperbaric Oxygen Therapy
Jehovah’s Witnesses with parental responsibility for children
If a child/young person is assessed as being ‘Gillick Competent’ they will be competent to
give consent to medical treatment. However, even if a child/young person is assessed as
being ‘Gillick Competent’, a refusal to consent to treatment can be overridden by a person
with Parental Responsibility who is acting in their best interests. This power to override the
competent child’s wishes should be treated with caution and advice should be sought in all
cases before preferring the wishes of the parents over those of the competent child. Parents
should be kept informed of all intended action by medical practitioners and be given the
opportunity to discuss their views on the use of alternatives to transfusion. The care and
well being of the child is the paramount concern. Whilst the parents’ wishes must be taken
into consideration, if after parental consultation, blood is declined, which is considered by
healthcare professionals to be in the best interests of the child, and the consequences of a
refusal are potentially very serious, then the Organisation may need to make an application
to the court for a declaration of what is lawful.
If it is thought to be in the best interests of the child to transfuse blood products, then before
proceeding down the line of obtaining a court order it is useful to:
1.
2.
3.
4.
Ensure the Hospital Liaison committee have been approached for advice
Ensure all non-blood medical management options have been explored
Consider the risks of giving the blood products
Explore if there is another hospital that could treat the patient without blood
products.
If having weighed up all the advantages and disadvantages, transfusion is still essential, it
may be necessary to seek a Court Order. It should be noted that Court Orders can be
obtained at short notice, whether during ‘office hours’ or out of hours (including weekends
and bank holidays). Ideally, the decision to seek a Court Order should be supported by two
consultants who are fully informed of the situation and aware of the alternative forms of
treatment; ideally this should include the Medical Director of the Organisation. The parents
need to be informed of the plan, and involved in any meetings or hearings, which will affect
the outcome. In exceptional emergency life threatening circumstances there may not be
enough time to apply to the court. If it is felt that a delay in the administration of blood may
be fatal, a decision to treat can be made against the parents’ wishes. Two Consultants who
are fully informed of the situation and are aware of the alternative forms of treatment must
make this decision. These Consultants must accept accountability for their decision. For
further information on when/how to seek a court declaration please refer to the
Organisations’ Policy for the Consent to Examination or Treatment
Staff Autonomy
In an elective situation staff have the right to refuse to treat Jehovah’s Witnesses but have a
duty to arrange a further opinion for the patient and/or a referral to a clinician who has
indicated willingness to treat Jehovah’s Witnesses.
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Confidentiality
The patient’s wishes will be paramount in deciding how much information will be give to
relatives and friends. Clinical information will only be given to other persons at the patient’s
request.
Prepared by: Hospital Transfusion Committee in conjunction with the Jehovah Witness
Liaison Committee.
Date:
October 2012
Review date: October 2014
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Appendix F
Blood Transfusion Crossmatch Request Form
BLOOD TRANSFUSION CROSSMATCH REQUEST
DATE AND TIME OF COLLECTION
Lab No
SURNAME
IW. No.
FORENAME
MALE  FEMALE 
SAMPLE COLLECTED BY:
CROSSMATCH DETAILS:
ADRESS/POSTCODE
DATE OF BIRTH
NO OF UNITS REQUIRED
……………………………………………………………………………….
DATE AND TIME REQUIRED
……………………………………………………………………………
NHS 
Private 
Temp 
Res
Cat II 
TO BE GIVEN  / TO STAND BY 
SPECIAL REQUIREMENTS
CONS/GP
CMV Neg 
LOCATION
COPY TO
Irradiated 
Other (Please State)
……………………………………………………………………………………….
ESSENTIAL INFORMATION
CLINICAL DATA INCLUDING DRUP THERAPY
PATIENTS BLOOD GROUP
PHONE BLOOD BANK FOR URGENT (SAME DAY) REQUESTS
LMP:
YES 
NO 
PREVIOUS TRANSFUSIONS YES 
NO 
ANTIBODIES DETECTED
EDD:
REQUESTIONG DOCTOR (print)
Singnatue:
ISLE OF WIGHT HEALTHCARE NHS TRUST
Date:
ISLE OF WIGHT PO30 5TG TEL (01983) 524081
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FAX (01983) 825437
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Appendix G
Blood Collection Slip
BLOOD COMPONENTS TO BE COLLECTED (No of Units)
Red cells
FFP
Platelets
Cryoprecipitate
Other
Patient Forename
Surname
IW Number
Date of Birth
_ _/_ _/_ _
Requested by:
Name
Time __ __
Date _ _/_ _/_ _
Ward
Emergency/Routine
Blood Transfusion Laboratory: Blood Collection Slip 21/10/908
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Appendix H
Financial and Resourcing Impact Assessment on Policy Implementation
NB this form must be completed where the introduction of this policy will have either a
positive or negative impact on resources. Therefore this form should not be completed
where the resources are already deployed and the introduction of this policy will have no
further resourcing impact.
Document
title
Policy For The Transfusion Of Blood And Blood Components
Totals
WTE
Manpower Costs
Training Staff
Equipment & Provision of resources
0
0
0
Recurring
£
0
0
0
Non
Recurring £
0
0
0
Summary of Impact: The policy of the Organisation regarding the requesting, sampling,
prescribing, transport, storage, administration, care of patient receiving and treatment &
reporting of an adverse event for blood and blood components based on National and
European Regulations and Guidelines
Risk Management Issues: This policy is document is designed to support effective risk
management across the Trust by decreasing the risk of patient exposure to errors and is an
important element of the risk management of patients in this Organisation
Benefits / Savings to the organisation: Effective risk management will support the Trust
to deliver its service efficiently, effectively with due regard to the financial envelope and
quality agenda. Failure to have this policy in place and implemented would mean that
patients lives potentially will be put at risk. Ultimately Chief Executives are at risk of being
prosecuted for non-compliance of the Blood Safety and Quality Regulations (2005), and the
Organisation’s would be in danger of losing their licence for being a Blood Establishment
Equality Impact Assessment


Has this been appropriately carried out?
Are there any reported equality issues?
YES/NO
YES/NO
If “YES” please specify:
Use additional sheets if necessary.
Please include all associated costs where an impact on implementing this policy has been
considered. A checklist is included for guidance but is not comprehensive so please ensure
you have thought through the impact on staffing, training and equipment carefully and that
ALL aspects are covered.
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Manpower
WTE
Recurring £
Non-Recurring £
Operational running costs
0
0
0
Totals:
0
0
0
Recurring £
Non-Recurring £
Staff Training Impact
Totals:
0
Equipment and Provision of Resources
Recurring £ *
Accommodation / facilities needed
Building alterations (extensions/new)
IT Hardware / software / licences
Medical equipment
Stationery / publicity
Travel costs
Utilities e.g. telephones
Process change
Rolling replacement of equipment
Equipment maintenance
Marketing – booklets/posters/handouts, etc
0
0
0
0
0
0
0
0
0
0
0
0
Non-Recurring £
*
0
0
0
0
0
0
0
0
0
0
0
Totals:

Capital implications £5,000 with life expectancy of more than one year.
Funding /costs checked & agreed by finance:
Signature & date of financial accountant:
Funding / costs have been agreed and are in place:
Signature of appropriate Executive or Associate Director:
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Appendix I
Equality Impact Assessment (EIA) Screening Tool
Policy For The Transfusion Of Blood And Blood Components
Document Title:
The transfusion of blood and blood products is an important, often
lifesaving, part of the treatment of many patients. It is also a procedure
that has an element of risk, with errors potentially leading to the death
of or long term damage to a patient who receives the wrong blood. This
forms the policy of the Organisation regarding the requesting, sampling,
prescribing, transport, storage, administration, care of patient receiving
and treatment & reporting of an adverse event for blood and blood
components based on National and European Regulations and
Guidelines
This policy aims to inform and guide healthcare professionals who are
involved in the transfusion process of safe transfusion practice and is
the shared responsibility of all staff involved in the various stages of the
Transfusion Process
Purpose of document
Target Audience
Person or Committee undertaken
the Equality Impact Assessment
Hospital Transfusion Team / Committee
1. To be completed and attached to all procedural/policy documents created within
individual services.
2. Does the document have, or have the potential to deliver differential outcomes or affect
in an adverse way any of the groups listed below?
If no confirm underneath in relevant section the data and/or research which provides
evidence e.g. JSNA, Workforce Profile, Quality Improvement Framework,
Commissioning Intentions, etc.
If yes please detail underneath in relevant section and provide priority rating and
determine if full EIA is required.
Gender
Race
Positive Impact
Negative
Impact
Men
N/A
N/A
Women
N/A
N/A
N/A
N/A
N/A
N/A
Asian or
Asian British
People
Black or
Black British
People
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Page 42 of 44
Chinese
people
People of
Mixed Race
White people
(including
Irish people)
People with
Physical
Disabilities,
Learning
Disabilities or
Mental
Health Issues
Sexual
Orienta
tion
Age
Transgender
Lesbian, Gay
men and
bisexual
Children
Older People
(60+)
Younger
People (17 to
25 yrs)
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Provides guidance on
treatment of patients who
refuse transfusions / blood
Faith Group
YES
N/A
components on the grounds
of religion. See Appendix E Guidelines – Jehovah’s
Witnesses & Blood
Transfusion
Pregnancy &
Maternity
Equal Opportunities
and/or improved
relations
N/A
N/A
N/A
N/A
Notes:
Faith groups cover a wide range of groupings, the most common of which are Buddhist,
Christian, Hindus, Jews, Muslims and Sikhs. Consider faith categories individually and
collectively when considering positive and negative impacts.
The categories used in the race section refer to those used in the 2001 Census.
Consideration should be given to the specific communities within the broad categories such
as Bangladeshi people and the needs of other communities that do not appear as separate
categories in the Census, for example, Polish.
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3.
Level of Impact
If you have indicated that there is a negative impact, is that impact:
YES
NO
Legal (it is not discriminatory under anti-discriminatory law)
N/A
N/A
Intended
N/A
N/A
If the negative impact is possibly discriminatory and not intended and/or of high impact then
please complete a thorough assessment after completing the rest of this form.
3.1 Could you minimise or remove any negative impact that is of low significance? Explain
how below:
3.2 Could you improve the strategy, function or policy positive impact? Explain how below:
3.3 If there is no evidence that this strategy, function or policy promotes equality of
opportunity or improves relations – could it be adapted so it does? How? If not why not?
Scheduled for Full Impact Assessment
Date:
Name of persons/group completing the full Andy Thompson
assessment.
Date Initial Screening completed
28/10/2015
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