The administration of blood and blood components and the management of transfused patients

Abstract

Errors in the requesting, supply and administration of blood lead to significant risks to patients. A survey of hospital blood transfusion laboratories in the UK in 1993 revealed 111 instances of blood being transfused to the wrong patient in an 18-month period (an incidence of 1 in 30 000 units transfused); 6 patients died and another 6 had serious morbidity associated with ABO-incompatible transfusions ( 17). A similar fatality rate was found in the United States (equivalent to approximately 1 in 500 000 units of blood transfused) ( 14). These deaths were due to errors either in the collection or labelling of the sample for blood grouping and compatibility testing, or in the laboratory, or to failure of the final pretransfusion checks. The incidence of ‘wrong blood’ episodes has changed little over several decades. This contrasts with the dramatic reductions in other hazards of transfusion such as viral transmission ( 1). Variation in the practice of the administration of blood is becoming increasingly evident from audit, both local and national ( 21), and from the first report of the Serious Hazards of Transfusion (SHOT) initiative ( 22). There are no recognized guidelines on which to base local procedures for the ordering and administration of blood and the management of transfused patients. In some hospitals, written procedures do not exist at present ( 21). Advice on some aspects of the administration of blood can be found in other 3 Committee for Standards in Haematology (BCSH) guidelines (BCSH, 1990, 5), and elsewhere ( 2; 16), but there is no single authoritative and comprehensive source supported by medical and nursing professional opinion. This is a document produced by the BCSH in collaboration with the Royal College of Nursing and the Royal College of Surgeons of England to set out the principles from which local policies and written procedures can be developed for: • requests for blood transfusion and the collection of blood samples for pretransfusion compatibility testing • the collection of blood and blood components from the hospital blood bank or other storage site and their delivery to the ward, operating theatre or other clinical area where the transfusion is to be given • the administration of blood and blood components • the documentation of transfusions • the care and monitoring of transfused patients • the management and reporting of adverse events • the staff responsible and the training required for these procedures It should be emphasized that there is little evidence to prove the efficacy of specific procedures to improve the safety of blood ordering and administration. The following represents a summary of current professional opinion. Inadequate patient identification or sample labelling may lead to ABO-incompatible transfusions ( 22; 18). Mistakes made in requesting blood may result in failure to provide the correct type of blood component, e.g. gamma-irradiated, CMV-seronegative ( 22). Common errors occur in: 1Patient identification, leading to a blood sample for blood grouping being taken from the wrong patient, or blood being transfused to the wrong patient, because of: • failure to ask the patient for his/her identification details • the use of secondary identifiers such as bed number, or the hospital notes or the request form the patient is carrying • failure to use patient identification wristbands • the failure to issue a patient identification number at the patient's initial contact with the hospital 2Sample labelling • prelabelling of the sample tube • failure to label the sample from one patient before taking the sample from the next 3Requesting blood • failure to indicate special blood requirements on request forms, e.g. gamma-irradiated 4Blood bank records • failure to check the previous patient record for blood group or for the presence of antibodies • failure to check the previous patient record for any requirement for special blood components, e.g. gamma-irradiated 5Telephone requests • failure to provide adequate information in terms of patient identification, number and type of blood or blood components required. Hospitals must have policies for blood transfusion requests and the collection of blood samples for pretransfusion compatibility testing. They must cover the following items: 1Definition of the staff authorized to request blood and to take and submit samples for pretransfusion testing. 2Request form The request form must contain full patient identification details, i.e. surname, first name, date of birth, the gender of the patient, and a patient identification number, which depending on the circumstances will be a hospital, accident and emergency number or major accident number ( 5). Even better would be use of a unique number for patient identification such as the NHS number. It is recommended that hospitals should avoid issuing more than one patient identification number during one admission to hospital. If a new patient identification number is issued, a new sample should be sent for pretransfusion compatibility testing and the laboratory informed so that the blood bank computer records of the patient can be merged. The request form should also contain other information, including: • the location of the patient at the time of the request, and also where the blood should be sent, if different • the number and type of blood or blood components, including any special requirements, and the time and date they are required • information about the past obstetric and transfusion history of the patient should be provided wherever possible, and is essential when there are anomalous pretransfusion testing results • the patient's diagnosis • the reason for the request It is also recommended that request forms should incorporate guidelines for the indications for the use of blood, and blood components to facilitate education of clinicians ordering transfusions and improve compliance with clinical transfusion guidelines ( 8). 3Requesting of special blood requirements Special blood requirements should be stored on the hospital blood bank computer, and hospital blood bank staff should check whether there are any special requirements whenever blood or blood components are requested. Hospitals must have a policy for the requesting of special blood requirements. In general, it is preferable that any special blood requirements are indicated on the blood transfusion request form each time blood or blood components are requested. However, the responsibility for providing special blood could be devolved to the hospital blood bank for transfusions to patients where special blood is always required, e.g. gamma-irradiated for intrauterine transfusions, and for transfusions to patients requiring special blood or blood components on a regular basis, e.g. haematology patients. 4Patient identification Positive identification of the patient is essential, based on: •questioning the patient by asking their surname, first name and date of birth in the case of patients who are judged capable of giving an accurate, reliable response •checking that the details on the patient's identification wristband match those on the request form and the answers to the questions above It is recommended that hospitals should have a policy for identifying inpatients, and patients undergoing daycase procedures such as blood transfusion or surgery with identification wristbands. The wristband should contain the patient's surname, first name, gender, date of birth and patient identification number. If the wristband is removed, for example to insert a cannula, it should be the responsibility of the person removing the wristband to resite the identification band. All patients including unconscious patients must have a patient identification number and identification wristbands including this number and the gender of the patient as minimum patient identifiers. When additional identification details become available, the hospital blood bank must be informed. 5Venepuncture Only one patient should be bled at a time to minimize the risk of error. 6Sample labelling •the sample tube must be labelled immediately after the blood has been added by the person taking the sample •sample tubes must not be prelabelled •the sample tube must be labelled with the minimum patient identification of surname, first name, date of birth, the gender of the patient, and patient identification number, and be signed by the person taking the sample, as set out in the 5 Guidelines for Pre-Transfusion Compatibility Procedures in Blood Transfusion Laboratories (1996a) •addressograph labels must not be used for sample labelling as these are more likely to result in inadequate patient identification ( 15; 10; 19) • date sample collected 7Inadequately completed request forms, inadequately labelled samples, and discrepancies between the information provided on the request form and sample •the hospital blood bank should have policies for dealing with inadequately completed request forms, inadequately labelled samples, and discrepancies between the information provided on the request form and sample, involving the retaking of the sample or providing additional information • if one or more of the patient identifiers is not provided on the sample in a life-threatening situation, group blood should be a labelled sample is If the patient is a blood should be ( patient records patient records must be in the hospital blood bank essential transfusion requirements may be ( 5). If a computer is in the must be at the of the request that there is an record for a patient with the name and date of if a computer is not in records should be by name and date of The hospital blood bank must the patient's and group previous records for the patient, and any discrepancies should be before blood or blood components are requests • the hospital blood bank should have a policy for requests • the of the person the request and the person it should both be • the following information should be patient's surname, first name, patient identification the number and type of blood or blood components required, including any special the reason for the the time and date the blood or blood components are required of blood and blood components from the storage location was as a major source of in the transfusion of the wrong blood in the report ( 22). errors were found to to of such and collection of the wrong blood was the site of the first error. errors at the time of collection because the blood was not for with the patient, but there were some when it was from blood bank staff to a or a of the clinical Hospitals should have a policy for the collection of blood or blood components from the hospital blood bank or other blood transfusion issue and delivery to the ward, operating theatre or other clinical area where the transfusion is to be and it should cover the following items: staff responsible for this must be stored in blood transfusion and not in or must be stored or in for this and which have been as for blood, including the time for which storage is It is practice for hospital blood to record the time when blood was a the time for which storage will be and to indicate that blood should be to a blood transfusion if it is not used that 4Patient and identification check •the staff removing blood from the hospital blood bank or other blood transfusion issue must have documentation the patient's identification details first name, date of birth and patient identification by of a blood collection or the patient's notes • if a request is given to a to blood, the must be given the patient identification details so that can these on to a blood collection and in should be given the location of the patient and the of that the blood or blood is required •the patient identification details first name, date of birth and patient identification on the collection or in the patient's notes must be by the staff removing blood from the hospital blood bank or other blood transfusion issue the patient identification details on the blood transfusion compatibility report the patient identification details on the compatibility label to the •the blood or blood identification details group and must be the details on the blood transfusion compatibility report the details on the compatibility label to the of blood from each blood transfusion issue should be including the name of the staff and the time the blood was blood and blood components are to a or operating a of staff should check that the correct blood has been and the blood collection including the time of delivery • the blood collection should be for at 1 of transfusion following delivery to the or operating theatre The transfusion of blood and blood components should as as after delivery to the or operating If this is not possible, it should be to a blood transfusion with the time of The transfusion of and should as as to the of the or If a of blood has been out of the for more than 30 and there is no of the hospital blood bank should be informed that it has been for more than 30 and the blood to the hospital blood bank for because of the risk of ( avoid of one of blood should be from a blood transfusion at a time for each patient transfusion of of blood is Errors at the time of administration of blood or blood components are the site of in the transfusion of the wrong blood ( However, errors in blood laboratory procedures and in of blood units from storage were found to be an in of the ( 22). Hospitals should have a policy for the administration of blood and blood components which should cover the following items: staff responsible for different aspects of this Blood and blood components are as for administration and should be by a or a current of the as a or of blood and blood components The of blood and blood components is the responsibility of a Blood and blood components should be on for or on special transfusion it is essential that the should contain the patient identification details first name, date of birth, the gender of the patient, patient identification The must • the blood or blood to be including any special requirements, e.g. gamma-irradiated, CMV-seronegative • the to be given • the of the transfusion for and 30 for an of or a of • any special e.g. any required before or during the transfusion information Blood transfusion must be any other i.e. patients should be informed of the for blood risks and and have the to to The patient should be given information about to blood including However, signed is not required. It is to provide patients with an information the risks and of blood the Blood has produced a patient information but produced information has the of taking the local of such as of the blood or blood It has been recommended ( that the hospital blood bank staff should check the date and blood and blood components before issue with • the of the by for at the and the • evidence of in the or at the between and • evidence of or • the presence of If there is evidence of any of the the should not be used and should be to the issuing Blood Transfusion It is practice for the staff blood or blood components to each in a similar before and to the to the hospital blood bank if any are check of patient and of blood The check is a in transfusion and staff must be in the patient's identification details match those on the blood transfusion report and the compatibility label to the blood This has of with at one being a or However, this is a and it has been that one responsible of staff would more out the than ( of staff may the other to be in giving the their full It is recommended that one of staff should be responsible for carrying out the check of the patient and the of blood at the patient's The of staff must be a or a current of the as a or It is recommended that the should have the following •the patient must be by asking his/her surname, first name and date of birth and that the and first name are the as on the patients It is essential that any patient a blood transfusion has an identification wristband with the patient's surname, first name, gender, date of birth and patient identification number. •the following details first name, gender, date of birth, patient identification must be and found to be on: the patient's identification the blood transfusion compatibility report the compatibility label to the blood the the medical notes • the blood group and number by the Transfusion on the of blood or blood must be and found to be to that on the blood transfusion compatibility report form • the blood group on the must be with the blood group of the patient indicated on the compatibility label to the blood If the blood group of the and the patient are not e.g. group blood to a group A patient or blood to an patient, the hospital blood bank should a specific on the compatibility report form to indicate that the blood is • the of blood or blood must be for compliance with any special requirements on the e.g. gamma-irradiated, CMV-seronegative • the of blood or blood must be to it has not or time in the case of components with a e.g. and • the blood transfusion compatibility report form the blood transfusion must be signed by the of staff carrying out the check and the date and time of the of the transfusion of each of blood or blood indicated on both If any discrepancies not by a on the blood transfusion compatibility report form are found during the the of blood or blood must not be The hospital blood bank should be informed and the and the blood transfusion compatibility report form to the blood of the blood transfusion compatibility report form The blood transfusion compatibility report form must be during the the location may from one clinical area to but each should have a policy for the location of the compatibility report form the transfusion is when it must be in the patient's medical notes as a record of the should be transfused a giving set for the A blood or administration set should be used for the transfusion of should not be transfused giving which have been used for Special giving should be used for transfusions to or a used if the transfusion is being by may blood and should not be used for the administration of they have been as to use for this to the is no minimum or of for The of should on the of the and the at which the blood is to be should be a with a and blood and blood components must not be such as the in a or on a ( A blood is • at of in in and for transfusions in • when patients with significant must not be added to blood any the giving set • a new giving set should be used after the transfusion has for more than in to • a new giving set should be used if another is to after the transfusion the transfusion • the should be to the hospital policy for of clinical of blood for a period of after transfusion has been recommended ( so that they are if a transfusion some after of the This can be to be but it is to and the are • the blood transfusion compatibility report form should be in the patient's notes The of patient care during transfusion is to the patient's transfusions should be for of the of transfusion and any with and There is in the of nursing during transfusion ( 21), and it is not the type and of should are likely to occur the first of the of each and patients should be during this Hospitals should have a policy for the care and monitoring of patients transfusions of blood and blood The policy should the staff responsible for the care and monitoring of transfused patients. information to be given to patient about adverse of and the of reporting immediately any adverse including of in or in the of the patient is the of patients during should be given in clinical where patients can be by of the clinical and of the of each should be indicated on and blood should be and before the of each of blood or blood component, and at the of each transfusion to transfusion should be from and to the information to be if should be on unconscious patients in operating and and should be after the of each of blood or blood during the transfusion of each of blood or blood are at the of each clinical area and be taken should the patient become or of a transfusion patients are more to for of transfusion should Transfusion should be when a or in the patient's during the first following the of a of blood or blood due to or may be the first indications of an transfusion in these patients. of the serious adverse events following blood transfusion are The are and transfusion transfusion and ( and transmission of 1). Hospitals should have a policy for the management and reporting of adverse events following transfusions of blood and blood components, and it should the staff responsible for this a transfusion is because the patient of or there are in a of the medical staff should be and the patient's and blood should be management on the type and of the of transfusion and their management are given in a is • the transfusion should be and medical • the blood administration set should be changed and to the • the should be immediately to the hospital blood The laboratory will request the of the and blood samples from the patient • nursing should be out at regular • the and of any should be of adverse events Hospitals should have a policy for and adverse events to blood including which should take • adverse events to blood transfusion should be to the hospital blood bank • if a is medical from a should be • adverse events to blood transfusion should be by the Transfusion Committee • serious adverse events blood or blood and transfusion including should be to the • of should be immediately to the local Transfusion documentation of transfusions is essential, for example so that the of serious adverse can be and of the for transfusions can be notes A record of the transfusion of blood and blood components and the administration of blood must be in the medical notes including: •the blood transfusion compatibility report form •the used for the of blood or blood components and for nursing during the transfusion in the case the for the use of blood or blood components, the the number and type whether or not it the and the and management of any adverse All documentation to the administration of blood other than that in the medical notes must be for at 1 including the request form ( the should to the documentation used for the collection of blood from a blood bank The blood sample for compatibility testing should be for 1 blood are required to records such as blood bank and and for at ( of staff are in one or more aspects of blood procedures are specific to one staff but can be out by more than guidelines should the of each staff and the required including and A of could be staff are responsible for blood, blood components and blood and for adequate documentation of blood transfusion in the medical nursing staff may out the following on local and be responsible for: • requesting blood, blood components and blood • taking blood samples for compatibility testing • the risks and of blood transfusion to patients • carrying out the for the administration of blood and blood components • monitoring patients during and carrying out the in the of adverse • reporting of transfusion or other to transfusion are • taking blood samples for compatibility testing are • the collection of blood, blood components and blood It is emphasized that this is a and errors in blood collection have been as an of administration of the wrong blood ( 22). in the hospital blood bank are responsible for: • that the labelling of request forms and blood samples with local guidelines • blood grouping and compatibility testing • whether there are any special requirements whenever blood or blood components are • that blood and blood components are and the identification details of the patient and the blood to be transfused are the on the compatibility label to the and the blood transfusion report form • the and reporting of transfusion or other to transfusion is responsible for: • that care are informed of and policies on blood transfusion for clinical ( of staff should be by the to be responsible for local policies for blood transfusion and the training of the staff in transfusion policies and procedures Transfusion Committee is responsible for: • transfusion policies and procedures • the for training of staff in transfusion policies and procedures • adverse transfusion events including • the of blood and about the use of blood and blood components • in transfusion where indicated • education in transfusion for of staff be local blood transfusion guidelines must the staff for they are of staff should be responsible for local policies for blood and that staff in blood transfusion adequate This should be to regular in blood transfusion policies and procedures must be in for medical and nursing hospital blood bank laboratory and any other staff in transfusion such as operating should occur for staff as of the training and risk management of staff and should be and by the risk management should be out that staff of transfusion should be by a specific training There has been in the use of information to errors in the clinical transfusion and in in the use of labelling of patient identification wristbands to patient identification by at the time of collection of samples for compatibility testing and at the time of administration of blood and blood to such could the identification of staff carrying out the administration of blood, the of nursing before and during the and the of a report for the medical notes ( for the use of information in blood transfusion ordering and of blood ( These new have the to in the of the administration of It is recommended that should be given to the of these for transfusion practice in A number of transfusions are being out in hospitals and in patient's The following should be in the of an hospital transfusion • a policy for transfusion should be taking the made in this document for hospital transfusion • the for the aspects of the transfusion must be set including responsibility for the • patients must be a patient identification number to be used the of blood including sample collection and the administration of blood • patients blood must have an identification wristband • there must be a of to be in case of an emergency or transfusion • training must be provided to staff in transfusion