Safe Transfusion Practice

Positive identification MUST occur at every step of the transfusion process: blood sampling, component selection, component administration and post transfusion observation.

Positive identification - Patient must state their full name and date of birth. Clinical staff MUST confirm details match those on wrist band / identifier. In cases where the patient has a reduced level of consciousness, confirmation should be performed with a second person reading details direct from wrist band.

Blood selection and administration requires a minimum of 4 identifiers to coordinate:

Last-name, first-name, date of birth and unique identification number¹ are required for provision of group specific products (providing sample testing to confirm patients’ blood group is available). Where possible the patient sex at birth must be stipulated.

Samples collected for grouping or crossmatching must also have phlebotomists initials included.

For casualties with unknown identity, the local unidentified patient protocol should be followed. This must involve unique identifiers, such as those detailed on casualty triage cards. Minimum data set is for patients with unknown identity are:

• Unique Identifier e.g. trauma number
• Service number
• Sex
• Time and date of sample collection

For casualties receiving universal blood components (Group O Red Cell concentrate /Whole blood, Group A Platelets and Group AB/A FFP) the above principles must still be followed to ensure patient safety and retain confidence in traceability documentation.

¹Regimental number, ZAP number or Unique trauma number generated in medical facility

Appropriate management of all transfusion related documentation is crucial to ensure transfusions are administered safely and that 100% traceability, a legal requirement[1] is achieved.

Blood and blood components must have uninterrupted traceability from donor to patient or final fate if not transfused.

Deployed units must liaise with the MoD Blood Establishment, the Centre of Defence Pathology (CD Path) or alternate approved blood establishment to ensure full traceability compliance.

All records associated with transfusion must be retained for 30 years.

If regulatory compliance is not met the MoD Blood Establishment license is at risk of being revoked by the Medicines and Healthcare Products Regulatory Agency subsequently UK blood supply capability to deployed locations.

BSQR 2015

Blood labels

Deployed clinical teams should be familiar with the additional blood component labelling used in Defence, the FMED 692. A copy at Fig 1.  The FMED 692 may be supplied with pre-printed as in the figure below or as an unprinted version FMED 692A for use by the laboratory deploying with a Laboratory Information Management System.

The FMED 692 (crossmatch label) will be attached to the blood/blood component bag using a zip tie or similar for issue.  It will reflect patient identifiers and include data that corresponds with the specific blood/blood component that has been issued.

Pre-Transfusion checks

Pre-Transfusion checks must be undertaken at the patient bedside.  If there is any discrepancy found with patient or component the unit must be returned to the blood bank/authorised holder for checking and re-issue.

Clinical staff must:

• Check the patient has consented and the blood component has been prescribed
• Check the component to be transfused is the right one and for the right patient.
  • Where practicable 2 person must be undertaken to ensure correct patient and blood being administered is correct.
  • Where employed this must be a double independent check by 2 trained clinical staff.
  • 1 person checks may be tolerated if two person checks are unachievable.
  • This may be associated with an increase in clinical risk.
    • In this circumstance all information should be double checked.
    • All staff must be aware of local policy and deviation from 2 person checks.
• Ensure positive patient identification.
  • It is essential that patients must be asked to state their name and DOB or clinical staff confirm unique identifiers.
  • The crossmatch label must be checked against prescription requirement in patient notes.
  • The wristband (if available) must also be checked.
  • All details must agree across all documentation. 
• Donation number and blood group of the unit must agree with the compatibility label.
  • The expiry date and visual check of unit integrity must be undertaken.
• Patient details and pack information must hand-written on the blue and pink by prescriber/non-medical authoriser.
• All detail must be accurate and legible.
  • Any error should have a single line through and be initialled.
• The blue sticker label is to be placed in the corresponding patient notes once the transfusion is initiated.
• The pink sticker label is to be sent to the Authorised Holder (BMS/BDSS/BSS qualified individual) as soon as practicable for collation and onward delivery to CD Path with consignment fate information.

The patient must be kept under close observation throughout the transfusion. Minimum observation requirements include Pulse, Temp, BP and RR. These should be undertaken up to 1 hour before the transfusion where possible, 15 mins after commencement and within 1 hour after completion.

Additional (SaO2, urine output and fluid balance) and increased frequency of observations may be required according to the patient’s condition e.g. risk of transfusion-associated circulatory overload (TACO) identified.

Early recognition and prompt management of transfusion reactions is vital to ensure patient safety. CD Path must be informed of any transfusion related anomaly as soon as practicable.

Additional clinical documentation should be undertaken at the following phases and include where practicable:

Pre transfusion:

• Indications for transfusion
• Consent - Essential, unless patient unconscious or confused, when HCP should act in patient’s best interests.
• Alternatives to transfusion
• Prescription / Authorisation

During transfusion:

• Start and finish time
• Observations recorded at indicated intervals
• Blood component donation number

Post transfusion:

• Management of any potential transfusion reactions
• Impact of transfusion on initial symptoms/ indications

All patients should be made aware transfusion has taken place during their treatment.

Effort should be made to ensure the environment the patient is being transfused in is optimised as much as is practicable to minimise risk.

Consideration should be given to monitoring of patients, staffing availability, cleanliness, environmental and other human factors. However, the risk of delayed transfusion in life threatening scenarios must be considered.

Non-urgent transfusion should not be conducted in a setting that is not appropriate or resourced.

Multiple staff may be involved in the transfusion process. Therefore, communication must be clear and accurate.  Poor communication can result in potentially fatal errors. 

Ten steps of transfusion are described by UK Serious Hazards of Transfusion (SHOT, Fig 2) and highlights the critical communication points in both clinical areas and areas from which blood is issued (laboratory/blood bank).

The use of the major haemorrhage protocols to guide major haemorrhage are crucial to effective delivery.  Clear communication from activation through to standdown will enable the team to have greater capacity for concurrent activity.

Deviations from protocols should be avoided unless there is clear clinical rationale. Any deviation is to be recorded in the corresponding quality system.

When runners are employed there must be one runner for one patient.

Regular clinical training and simulation of the transfusion system in encouraged, including major haemorrhage, Emergency Blood Collection and routine transfusion scenarios.

Gaining consent for treatment before transfusion is best practice and should be documented.  Consent in advance not always possible.

Clinical team should act in best interests of the patient all times. Concerns related to consent should not delay urgent transfusion.

Patients should be informed retrospectively if they received a transfusion and counselled accordingly.

This aide memoire for transfusion in MTF setting and does not replace formal training

At the casualty

Transfusion request

• Complete FMED 17A with patient identifiers (patient demographic stickers if utilised must be signed by the requestor)
• FMED 17A – clinician request and sign for blood components and crossmatch. This must include:
  • Blood component type
  • Blood component quantity
  • Urgency
• Consent where applicable

Blood sampling 

• Identify patient and confirm identity
• Collect sample into transfusion EDTA tube (pink topped). Fill to line.
• Label sample immediately after bottle filled (not before) and at patient’s bedside and mix gently.
• Minimum data required for emergency samples, unknown patients.
  • Trauma number
  • Service number/Zap number
  • Sex
• Time and date sample
• Minimum data required for non-urgent samples
  • Unique number
  • Sex assigned at birth
  • Full name (if known)
  • Date of birth (if known)
• Time and date sample
• All samples MUST have Initials of phlebotomist
• Send sample with FMED 17A to laboratory asap

Laboratory/Blood bank

• Collection point for blood components
• One runner, one casualty
• Runner requires patient identifier for product collection
  • Drug chart or trauma pack label.
• Check
  • Blood component expiry date
  • Label on blood component matches details of casualty
• Collect
  • Blood component(s) with attached FMED 692
• Sign
  • For each blood component with date and time (FMed 692)
• Deliver
  • Blood component(s) and paperwork directly to HCP responsible for casualty

Transfusion:

• Complete transfusion monitoring and record
• Retain BLUE slip from FMed 692 in medical record and return PINK slip to Authorised Holder (BMS/BDSS/BSS) trained personnel at earliest opportunity.
• If any concerns of adverse reaction, see transfusion reaction CGO for management and document accordingly.