Download Principles of intravenous infusion/ blood transfusion (CFP)

Hazards of IV therapy
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Aim:
To raise awareness of hazards
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Learning outcomes:
Recall the role of the nurse in IV therapy
List the main risk factors of IV therapy
List complications to the patient of IV
therapy
Howard Griffiths, SHS
Underpinning knowledge
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Basic anatomy and physiology
of the cardiovascular system
Principles of asepsis
Pharmaceutical knowledge of
different fluids
Drip factors and different giving
sets, their purpose
Technical knowledge of
different pumps that may be
used
Howard Griffiths, SHS
Role of the nurse
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Identifying and verifying prescription
Checking for contamination and faults
The 5 R,s of drug administration
Controlling the prescribed flow rate
Monitoring and reporting patient’s
condition
Ensuring that IV device remains patent
Inspecting the insertion site, reporting any
abnormalities
Maintaining records
Howard Griffiths, SHS
Nursing interventions
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Good hand washing and universal
precautions
Drug administration calculation
Vital signs measurement during
therapy (BP, pulse, respiration,
temperature)
Degree of consciousness of the patient
Observe urinary output and maintain
fluid balance chart
Report blood results of urea and
electrolytes to doctor
Observe for local signs of infection at
the cannula site Howard Griffiths, SHS
Methods of administration
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Intermittent fluids
Continuous fluids
Parenteral nutrition
IV bolus medication
IV intermittent injection of
medication
Howard Griffiths, SHS
Managing Risks
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Infection control
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Drug interactions
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Correct use of syringe and infusion
equipment
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Correct checking procedures for drug
administration
Howard Griffiths, SHS
Therapeutic use of Intravenous fluids
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To maintain hydration
To correct fluid and
electrolyte balance
To administer bolus IV
systemic medication, such as
prescribed antibiotics
To maintain haemodynamic
stability during surgery, and
or maintain stability during
pathological crisis, e.g shock
Howard Griffiths, SHS
Factors to consider when administrating drugs
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Does it require reconstitution
storage
stability
expiry date
drug action and side-effects
what is it incompatible with
physiological considerations, serum levels?
is protective clothing required?
Howard Griffiths, SHS
Drug interactions
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inadequate mixing of drugs
fluid may have an affect on the stability of the
drug
drug degradation through light (frusemide,
nitroprusside, vitamin A and K)
inadequate mixing of drug additives
specific gravity of the added drug may be different
from fluid used, resulting in layering
Howard Griffiths, SHS
Patient related factors in drug administration
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The 5 R’s
allergies
body mass
vital signs
informed consent
clinical status
do they understand the side-effects
is the device patent?
Howard Griffiths, SHS
IV administration sets
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Use aseptic technique when handling
Latex bungs and injection ports, clean
with 70% alcohol, and allow to dry
before administrating drugs
Clear fluids/ stored plasma/ drug infusion
should have:
– standard administration sets (5-15
micron filter, 20 drops per ml).
– Burette or buretol (15 micron filter, 60
drops/ml)
Howard Griffiths, SHS
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Transfusions
– blood administration sets (15 drops/ml)
should be used for blood and fresh frozen
plasma (FFP)
– Albumin Solution, Hetastarch and
Haemacell can be given through clear fluid
sets, as they contain no cells
– Platelets and Cryoprecipitate is
administered through a platelet set (15
drops/ ml)
Howard Griffiths, SHS
Factors affecting flow rates
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Fluid composition, viscosity and concentration of fluid
Height of fluid container will alter the hydrostatic pressure
of fluid
Change in the position of the client’s access site
Administration sets
– distortion of tubing may render the clamp ineffective
– diameter of the lumen
– inclusion of in line devices such as filters
Vascular access
– condition and size of vein
– cannula gauge
– occlusion
Howard Griffiths, SHS
– pressure
Infusion devices
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Medical Device Agency has
identified one of the most serious of
medication errors involve the use of
infusion pumps
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One of the main areas where human
error occurs is in drug calculation
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The MDA has categorised infusion
devices in terms of
risk:
Howard Griffiths, SHS
– Neonatal risk infusion
requires high accuracy and consistency of flow, used in
neonatal intensive care and paediatric services
– High-risk infusion
similar to above but not as accurate over the short term
(within 1 hour). More suitable for older children and adults.
– Low-risk infusion
infusion of simple electrolytes, antibiotics and total
parenteral nutrition. Devices will not need to have accurate
or consistent output, only rudimentary alarm and safety
systems
– Ambulatory infusion
infusion devices worn to allow normal activities during
infusion, often battery powered
Howard Griffiths, SHS
Infusion device checklist
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Uncontrolled flow
– occur from gravity drips, volumetric and
syringe pumps
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Selecting the right infusion pump for
transfer
– is it necessary to take all infusion devices,
does the pump meet the risk classification?,
is the operator trained to use it
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Changing the infusion during transit
– avoid, calculate infusion requirements and
prepare so that the infusion will last the
journey
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Security and safety
– ensure that all devices are fixed or clamped
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secured
Flushing and maintaining patency
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Ensures that the whole drug is given
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Ensures that the device remains
patent
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0.9% NaCl is effective in maintaining
patency in peripheral devices
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Flushing should be undertaken after
each dose or at least every 24 hours
Howard Griffiths, SHS
Issues of infection control
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Transparent film dressings over catheter or cannula site
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Change local dressings according to local protocols
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Keep change of IV infusion bags, giving sets, disconnection
or interruption to a minimum
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Hand washing and asepsis should be maintained before
manipulating the IV system
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With minimal breaks in IV circuit, change administration
sets every 72 hours.
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With frequent breaks in IV circuit, change administration set
every 24-48 hours. For blood products change after
infusion.
Howard Griffiths, SHS
Fluid and blood product administration
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DO NOT ADD
DRUGS TO:
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blood products
mannitol
sodium bicarbonate
parenteral nutrition
Ensure individual
drugs and solutions
are given by the
optimal route Howard Griffiths, SHS
Chemistry of body fluids
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Electrolytes
– it is common to measure
electrolytes in ECF, chiefly the
plasma.
– The term ‘plasma’ and ‘serum’ are
used interchangeably
– Na+ is the main cation in ECF and
controls the volume of fluid in ECF
– K+ is the main concentration of
ICF.
Howard Griffiths, SHS
Intravenous fluids
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Correcting and maintaining fluid and
electrolyte balance
– isotonic fluids are prescribed fluids that
do not alter the osmotic movement of
water across cell membranes.
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0.9% Sodium chloride is used to sustain
extra cellular fluid volume by compensating
for volume lost be
– dehydration
– urinary excretion of sodium
– fluid drains following surgery
Howard Griffiths, SHS
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Hypertonic fluids are fluids that
expand intravascular volume by
moving endothelial and intracellar
water into the intravascular space
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These fluids contain a high
concentration of particles when
compared to plasma, has potential
therefore to cause fluid overload.
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These fluids also has the potential to
irritate peripheral veins,
administration should be slow
Howard Griffiths, SHS
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Hypotonic saline (0.45%) is used
to replenish electrolytes.
Complications can include over
hydration, sodium overload and
potassium defecit.
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Hypotonic fluids drive fluid from
the plasma into the interstitial
space, and therefore are used to
re-hydrate the cells
Howard Griffiths, SHS
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Potassium electrolyte infusion is
used for patients with severe
hypokaelaemia.
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Conditions leading to
hypokalaemia are– vomiting, diarrhoea, use of potent
diuretics, malnutrition, some forms of
renal diseases and metabolic acidosis
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Careful infusion is required in order
to avoid cardiac arrhythmias and
death.
Howard Griffiths, SHS
Peripheral site complications
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Phlebitis
– caused by mechanical rubbing of cannula, or
chemical irritation from fluid, or through
contamination through poor hand washing by the
nurse
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Occlusion
– caused by incorrect flushing, empty bags, kinking
of line, precipitation, poor cannula site
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Infiltration
– a none blistering drug leaks into the surrounding
tissue
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Extravasation
– blistering drug that leaks into surrounding tissue
Howard Griffiths, SHS
Potential systemic complications of IV
therapy
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Circulatory overload
Systemic infection
Air embolism
Allergic reaction
Howard Griffiths, SHS
Types of central venous access
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Peripherally inserted catheters
(PICCs)- for patients requiring several
weeks of IV access
Short term tunnelled catheters- days to
several weeks of IV access
tunnelled cuffed catheters- for long
term intermittent continuous or daily
IV access
Implanted venous access- for long
term, intermittent, continuous or daily
IV access
Howard Griffiths, SHS
Immediate Complications of central venous
catheters
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venous air embolism
tamponade
catheter embolus/rupture
arterial puncture
dysrhythmias
pneumothorax
Howard Griffiths, SHS
Delayed complications of central venous
catheters
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Infection of tunnel
infection within catheter
occlusion
drug precipitation
thrombosis
air embolism
anaphylaxis
broken hub, broken clamp, split
catheter
catheter pulled or fallen out
Howard Griffiths, SHS
Safety issues in Critical Care
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Labelling of sets
– Functions of different sets must be clearly labelled
– above will help prevent mal-administration of drugs
and avoid haemodynamic monitoring sets
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Identify both proximal and distal end of a giving set
Use uninterrupted tubing, free of junctions and access
ports
Only use high pressure tubing for haemodynamic
measurements
If stopcocks have to be used on administration sets,
clean with 70% alcohol beforehand
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Howard Griffiths, SHS
Blood products
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Whole blood transfusion
Packed RBC
PlateletsFresh frozen plasma
Cryoprecipitated antihemophilic
factor
Granulocytes
Serum albumin and plasma
protein fraction (PPF)
Howard Griffiths, SHS
Therapeutic use of blood products
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Whole blood transfusion
– for massive blood loss in neonates
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Packed RBC
– for inadequate oxygen carrying capacity
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Platelets
– for treatment of thrombocytopenia, acute lukaemia,
and marrow aplasia, and to restore platelet count
preoperatively inpatients with a count of
<100,000/mm3 or less
Howard Griffiths, SHS
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Fresh frozen plasma
– for expansion of plasma volume, treat post-op
haemorrhage or shock and correct coagulation
factor deficiencies
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Cryoprecipitated antihaemophilic factor
– for haemophilia A, von Wilerbrand’s
disease, hypofibrinogenemia
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Granulocytes
– for severe gram negative infection or severe
neutropenia unresponsive to routine forms of
therapy in immunosuppressed patient. Also
indicated in severe granulocyte dysfunction.
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Serum albumin and plasma protein
fraction
– in hypovolaemia and hypoproteinemia (burns)
Howard Griffiths, SHS
Managing Clinical Risk
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Human error has been recognised as a
cause of transfusion fatality for several
decades (BMJ 1953)
Errors can occur :
– time of blood sample collection
(incorrect labelling, blood taken
from the wrong patient)
– within the laboratory (use of
incorrect sample or patient record;
release of wrong unit from the
store)
– practice settings (administration to
the wrong patient)
Howard Griffiths, SHS
Managing Clinical Risk
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There is no mandatory reporting
system in the U.K.
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A voluntary system operates
through Serious Hazard of
Transfusion (SHOT) initiative
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Anyone can report a blood
transfusion error, adverse
incident or error to SHOT
Howard Griffiths, SHS
Good Practice required for blood transfusions
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All blood products should be correctly prescribed
by the doctor:
– specify quantity and note any allergies
– duration of the transfusion, special requirements of the blood or
blood product and precautions
– reason for transfusion should be documented in the medical
notes
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Other methods should be considered:
– autologous blood transfusion
– intra-operative blood salvage
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No formal consent is required in the UK but
information provided should cover:
– reasons for transfusion
– details of the benefit and risks of such treatment
Howard Griffiths, SHS
Good Practice required for blood transfusions
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Follow local policy when collecting blood:
– compatability reports filed in the patient’s notes
– signatures of authorized staff collecting the blood
– time of collection
– storage of blood should be in a refrigerator at -2.6c
– blood transfusion should commence within 30 minutes of its
removal
– blood transfusion should be completed within 5 hours
(proliferation of bacteria in blood components)
Howard Griffiths, SHS
Good Practice required for blood transfusions
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BCSH 1999 guidelines state that a single
practitioner (midwife, nurse or doctor) can verify
details at the bedside, in order to reduce risk of
errors.
Pre-transfusion checks should include:
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expiry date
leakage
unusual colour (brown or red plasma indicates haemolysis)
patients details, and ABO and Rhesus group
unique donation number
The blood unit details should be checked against the
doctor’s prescription, compatibility report and
identification number
Howard Griffiths, SHS
Good Practice required for blood transfusions
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Patients should have an I.D. band containing accurate
information
The bag should be gently squeezed for leaks, and gently
rocked to mix the contents
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A standard 19 gauge IV cannula and a blood giving set
should be set up which has filter to prevent small clots
entering the blood stream.
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Administration of platelets should be through a platelet
giving set, not a blood transfusion set (special paediatric
sets are for infants).
Giving sets should be primed only with N/Saline
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Howard Griffiths, SHS
Good Practice required for blood transfusions
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A blood warmer is indicated:
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a flow rate of >50mL / Kg / hour in adults
a flow rate of 15 mL/ Kg/ hour in children
exchange transfusions in infants
transfusing patients with clinically significant cold agglutins
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No other drug or fluids should be added to the
transfusion set which may cause red cells to clot or
lyse
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The giving set should be changed:
– after 12 hours
– if another infusion is to continue after the transfusion
Howard Griffiths, SHS
Good Practice required for blood transfusions
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Nursing observation required according to BCSH
guideline 1999 are:
– baseline observations to include temperature, pulse and BP
– pulse and temperature are additionally observed within 15
minutes of the start of each unit of blood.
– nurse all patients receiving blood in a location where they
can readily be observed
– additional observations are only necessary when a patient is
unwell or noted to have deteriorated.
– observe urinary output and maintain fluid balance chart
Howard Griffiths, SHS
Good Practice required for blood transfusions
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observe patient’s behaviour during transfusion
observe the appearance of the patient during transfusion
check cannula for signs of infection
adverse reactions should be reported immediately
acute haemolytic reactions, transfusion must be stopped and
further assessments carried out.
After completion of transfusion:
– the transfusion should be disposed of according to local
policy for disposal of clinical waste.
– Retention of blood bags for 48 hour period as been
recommended by BCSH 1990, in case there may be a
severe reaction some hours after discontinuation
Howard Griffiths, SHS
Potential complications of blood transfusions
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Infection
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Febrile reaction
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Allergic reaction
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Transfusion hypothermia
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Fluid overload
Howard Griffiths, SHS
Adverse reaction
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Increase in temperature
Hypotension
Tachycardia
Headaches
Rashes
Swelling around cannula site
Pain in abdomen or chest
Patient feeling agitated or unduly apprehensive
STOP TRANSFUSION, CONTACT DOCTOR
AND FILL DOCUMENTATION
Howard Griffiths, SHS
Reporting adverse incident
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recheck the blood against the patient’s notes
check the patient’s urine for blood
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blood needs to be cross matched again
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all equipment (blood bag, giving set and urine )
should be sent to the lab for testing
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keep the iv line open with 0.9% normal saline
complete the employer’s adverse clinical incident
form, and document in care plan
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Howard Griffiths, SHS
Conclusion
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IV therapy must be prescribed by a medical
practitioner
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Cannulation and insertion of catheters,
together with administrating IV medication is
regarded as extended Professional Scope of
Practice.
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Always check that equipment, the fluids and
the flow rate with another R.N.
Howard Griffiths, SHS
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The bedside check is the final opportunity to
prevent a mis-transfusion
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Each hospital will have a formal policy which
must be followed for blood transfusion
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Every patient should have an uniquely
identified wristband
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Each R.N must ensure responsibility regarding
their competency .
Howard Griffiths, SHS
REFERENCES
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British Committee for Standards in Haemotology, Blood
Transfusion Task Force (1999) The administration of blood and
blood components and the management of transfused patients;
Transfusion Medicine 9:227-238
Jane Mallet and Lisa Dougherty (2000) Manual of Clinical
Nursing Procedures (5th edition); Blackwell Science, London
Fox, Nick (2000) Managing risks posed by intravenous therapy;
Nursing Times Vol.96 (30), pp37-39
R.C.N. ( ) Guidance for Nurses Giving Intravenous Therapy
Serious Hazards of Transfusion (SHOT) Annual Report 19992000:Availavble from; htpp://www.shot.demon.co.uk/
Quinn, C. (2000)Infusion devices: risks, functions and
management; Nursing Standard Vol. 14 (26):35-41
Wilkinson, J. (2001) Administration of blood transfusions to
adults in general hospital settings: a review of the literature;
Journal of Clinical Nursing Vol. 10 (10):161-172
Howard Griffiths, SHS