Safe Blood Transfusion Cardiff & Vale uhb & Welsh Blood Service Education Sub-group
Objectives Complex pathway Overview ~ pre-transfusion blood sampling ~ collection from blood bank fridge ~ administration ~ adverse events
How many units are issued in the UK per year? Approximately 3 million
How much does each unit of blood cost? 150
(SHOT 2008)
(SHOT 2008)
Number of Blood Transfusion Incidents per month 2009 (C&V 2009) 100 90 80 70 60 50 40 30 20 10 0 April May June July August September October November
Sample Labelling Errors (C&V 2009) 18 16 14 12 10 8 6 4 2 0 April May June July August September October November
Phlebotomists patient ID error results in 3 unit ABO-incompatible transfusion (SHOT 2008) An elderly gentleman required an amputation for gangrene and was grouped as B RhD positive. 3 units of B RhD positive red cells were transfused in the perioperative period. A post-operative sample taken a few days later prior to a laparotomy grouped as O RhD positive. The patient had in fact suffered some respiratory problems, further anaemia and hyperbilirubinaemia following his original transfusion, but these had been attributed to his multiple co-morbidities and possible fluid overload. The patient eventually died of complications unrelated to his ABOincompatible transfusion. The incorrect sample had been taken from the wrong patient by a phlebotomist.
Wrong blood in tube incidents (C&V 2009) 7 6 5 4 3 2 1 0 April May June July August September October November
Pre-Transfusion Sampling
Sampling: Background Critical Process
Sampling : Check the form Essential details on the request form are:- First & Last names DOB Address Hospital No. Gender Signature of person making the request with contact details - legible No form = No phlebotomy
Prevent the Event Basic Principle
Sampling : Patient identification At the bedside Conscious patients Verbal + confirmation with wristband or alternative Unconscious/Paediatrics/Unable to provide verbal I.D. Wristband or alternative
Sampling: Patient identification Use the patient s wristband as part of your checking procedure
Sampling : Labelling Minimum labelling is:- Full name, DOB, 1 st line of address, Hospital Number, Gender, Date and Signature Handwritten by whoever takes the blood at the bedside Think about ink! No addressographs No pre-labelled bottles
Blood Collection from a Blood Bank fridge
(SHOT 2008) Red cells administered instead of platelets A unit of platelets was prescribed for administration overnight, with a further unit of red cells to be given in the morning. Although the staff nurse believed she had given a unit of platelets, she had collected and transfused a unit of red cells, administering the component over 50 minutes as per the platelet prescription. The prescription form was completed with confirmation of bedside checks. When questioned, the nurse stated she did not know the difference between a bag of red cells and a bag of platelets.
Collection : Background Critical Process
Collection:Request Always have written patient I.D. information when collecting blood components with:- First & Last names DOB Address Hospital Number/other number
Collection:Recording Match Patient ID with unit removed Record the unit ID Date, Time and Signature legible The documentation is crucial Close fridge door! Transport considerations
Collection:Transport Transport the component to the appropriate clinical area without delay Red cells and FFP can go in a designated transport box Platelets must never be refrigerated
Transport Boxes Use only when absolutely necessary Blood can be kept in a transport box for 2 hours Blood components at room temperature cannot go back into blood bank after 30 minutes Do not request blood unless you intend to give it & are ready to give it ~ avoid wasting blood
Collection:Delivery Receipt of unit Ward staff will acknowledge receipt of the correct unit to include:- Date Time Signature
Return of Unused Units Documentation is crucial Date Time Signature
Blood Administration
(SHOT 2008)
Over-estimation of blood loss from GI bleeding leads to massive over transfusion (SHOT 2008) An elderly inpatient had a coffee ground vomit and some melaena. IV fluids were administered and an FBC showed as Hb of 14.3 g/dl. Her Hb the previous day had been 14.7 g/dl. Observations were initially stable, but her BP suddenly dropped and 2 units of red cells were transfused. Twenty minutes later, after another haematemesis, a further 2 units of red cells were transfused. No repeat FBC samples were taken due to poor venous access. Two hours later, the BP was stable, and a further 2 units were transfused. The Hb later that day was 16.6 g/dl, rising to 18.3 g/dl that night, and 20.8 g/dl the following afternoon. The patient died on the evening of the following day.
Blood Administration: Background Critical process Perform for each unit
Pre-transfusion Check: 1 Preliminary Requirements Availability of staff Patient with wristband Patent venous access Correctly completed prescription Observation chart Giving set (170-200 microns) and other equipment Perform checks at the bedside
(SHOT 2008) Overnight transfusion prescribed for 4 hours not monitored and runs for >10 hours A unit of red cells was collected from the blood bank at 2110. According to documentation, transfusion was commenced at 2130 by a trained trust bank nurse and an agency nurse, with the prescription for transfusion over four hours. The transfusion was not recorded on a fluid balance chart. The bank nurse went home at 2300, and the agency nurse took responsibility for the patient. Day staff took over at 0800, and the unit was still running. The transfusion was eventually stopped at 0830, more than 10 hours after commencement.
(SHOT 2008) Lack of ID checks at patient s side A haematology patient required a second unit of red cells, so the registered nurse looking after the patient co-opted a second registered nurse to perform the patient ID check. All the documentation was completed and signed by both nurses at the nurses station. The first nurse then took the unit into the 6-bedded bay alone, and administered the blood to the patient opposite the one for whom it was intended, without a bedside ID check. An A RhD negative patient was thus transfused with a unit of group O RhD positive red cells. No transfusion observations were conducted. Both nurses had received transfusion training within the previous 12 months.
Pre-transfusion check One person or two person checking?
(SHOT 2008)
Pre-transfusion Check: 2 Suitability of blood component Quality of component (Look for clots, leaks etc) Expiry date Special requirements - CMV negative - irradiatiation - blood warmer?
Pre-transfusion check: 3 Positive patient identification Traceability label must match patient ID Conscious patients verbal check + wristband or alternative Unconscious/paediatrics/unable to identify self for any reason wristband or alternative
Administration Pre-transfusion observations Start transfusion Date, time and sign - legibly NB: Infusion time for red cells should ideally not exceed 2 hours Platelets & FFP can be given within 30 minutes Don t allow blood components to warm up before you give them (or put them in drug fridges)
Observation Do not leave the patient unattended for the first 15 minutes Record vital signs at 15 minutes Record vital signs on completion of transfusion Record vital signs more often if you are at all concerned about the patient Document the transfusion stop time
Documentation All documentation relating to the transfusion must be correctly filed in the patient s medical records
European Directive 2002/98/EC Blood Safety & Quality Regulations 2005 (50) www.europa.eu.net
Traceability Emergency O negative blood Human Albumin Solution, Immunoglobulin and other fractionated products
Adverse Incidents Observe the patient and ask him/her to report any of the following: Fever chills tachycardia hyper/hypotension collapse rigors flushing urticaria bone muscle chest and/or abdominal pain shortness of breath nausea generally feeling unwell
(SHOT 2008)
ATR: Commonest reactions by component type
Adverse Incidents Stop transfusion Record vital signs Call doctor Re-check component and patient ID Role of the Laboratory
Other Frequently Asked Questions Can blood components be given via mechanical infusion pumps? Do I need to prime giving sets with saline and flush them after with saline? Can we transfuse overnight? Blood giving sets how many units can I give through a set? What about FFP and platelets? Does the cannula size matter?
Useful Sources of Information www.learnbloodtransfusion.org.uk www.bcshguidelines.com www.transfusionguidelines.org
Any Questions? Lisa Griffiths, Transfusion Practitioner Gary Hathaway, Senior BMS, Assistant Transfusion Practitioner UHW Ext 4594 Pager 07699 781 543 or through Switch
Interested in donating blood? 0800 252 266 Mondays Thursdays 9 am 9 pm Fridays 9 am 5 pm They will advise you as to your nearest session www.welsh-blood.org.uk http://www.medindia.net/animation/blood -groups.asp