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Discussion - Part
3
(Administering Blood Products)
This section will review best practices for
administering blood transfusions. The discussion is not meant to be definitive or all inclusive.
Protocols for Patient
Identification
As discussed, identification errors often occur
at several stages in the transfusion process, including
immediately prior to transfusion when identifying patient and donor units.
Consider these cases from the 2004 SHOT Report:
In 40 cases there were errors in blood
collection and administration to the patient. In 23 of these the
wrong component was collected from the refrigerator and the error
was not detected at the bedside, in 17 the blood was correctly
delivered to the ward but was given to the wrong patient.
A common feature of these cases, documented in 17 of the 40
reports, is that the blood was 'checked' away from the patient's
bedside against a compatibility form [blood unit label / tag],
and no wristband or other identity check was carried out. The
patient details on the compatibility form will always match those on
the blood pack and checking one against the other does not
constitute an identity check.
Case 3
A porter was sent to the blood bank to collect a unit of blood for
Fred Bloggs, whose blood group was AB D negative. He collected the
correct unit but delivered it to the wrong ward, where Jane Smith,
who was Group O D positive, was being transfused. On seeing the unit
of blood, the staff nurse assumed that it was the second unit for
Jane Smith. The staff nurse and deputy ward sister checked the
unit of blood against the compatibility form away from the patient's
bedside and transfused it without a bedside id check. Later that
evening the ward where Fred Bloggs was being treated phoned the lab
to say that the blood had not arrived. It was not traced until the
next morning when the transfusion practitioner found the empty pack.
The ward had noticed that Jane Smith had become jaundiced but did
not associate this with the transfusion. She developed acute renal
failure requiring dialysis from which she recovered, but her planned
surgery for a hip fracture was postponed for 4 weeks during which
she was immobile. Post-operatively she developed hypostatic
pneumonia from which she died.
Learning points:
- The final identity check when taking a
blood sample or administering blood MUST be done at the
patient's bedside against a wristband or equivalent form of
identification. No other form of checking is acceptable under
any circumstances
- The final patient identity check at
the bedside must never be omitted, however urgent the clinical
situation
The following is an
example of a best practice
identification protocol (others may be equally valid). For more
protocols, see
Online Resources & References
- If the patient is
alert, ask the patient to state his or her name.
- Verify the patient's
identification information (first and last names, hospital
identification number or equivalent) on the blood unit label with the information on
the recipient's wristband.
- Verify that the component type and donor number on the hospital
blood bank label matches the information on the blood supplier
label. Note: Do not miss this
step, since the component may be mislabelled (mis-tagged in the
blood bank). It is analogous to the requirement to check not only
the pharmacy label but also the label on the vial or bottle to
ensure that the correct label is on the correct medication.
- Verify that the blood product is not outdated.
- This identity check
must be performed by two qualified health professionals* trained in
blood administration procedures, according to facility protocols.
- If any discrepancy
is noted:
- Notify the transfusion service laboratory immediately
and return the blood product.
- Document the names of
the two individuals performing the identity checks in the appropriate
record.
- Record the name of the
person beginning the transfusion. This person must be trained in
blood administration.
- Record the date and time the transfusion was started.
If a Typenex bracelet is
used:
- Two qualified health
professionals* must verify that the Typenex bracelet matches the
information on the patient wristband and the blood unit.
- Make sure the Typenex
number on the bracelet matches that on the blood unit.
*Issue
#1:Two
qualified health professionals?
Are
two
health professionals required to confirm the patient and donor
identification information at the bedside prior to transfusion?
Although many facilities require two health professionals to verify
patient identity and that the correct blood is transfused, Canadian
(and other) blood safety standards do not require a 2-person check (see CSTM
Standards, L2.2 below). Neither do AABB Standards, as discussed on the
CBBS e-network forum*. Although the discussion is from 2001–2002,
the AABB Standards still do not require a 2-person check.
* Are
two people needed to verify that the correct blood products are
issued and transfused?
In the UK the
BCSH
guidelines (C.5. Administration of Blood
and Blood Components - Identity check of patient and unit
of blood) recommends a 1-person check:
The bedside check is a vital step in preventing transfusion error,
and staff must be vigilant in checking the patient's identification
details match those on the blood transfusion report form, and the
compatibility label attached to the blood pack. This procedure has
traditionally involved two members of staff, with at least one being
a qualified nurse or doctor. However, this is a controversial area,
and it has been argued that one responsible member of staff would
more reliably carry out the procedure correctly than two (Linden &
Kaplan, 1994). Two members of staff may rely upon the other to be
rigorous, resulting in neither giving the task their full attention.
It is recommended that one member of staff should be responsible for
carrying out the identity check of the patient and the unit of blood
at the patient's bedside.
Regardless of the lack of a regulatory requirement for a 2-person
check, many facilities use one in the belief that a second check
increases safety by decreasing the risk of misidentification errors.
Even with a 2-person check, in some facilities two people check the
patient's chart, requisition, and unit to be transfused at the nursing
station but only one person (the person administering the product)
checks the wristband at the bedside.
- It is critical that patient identity be
confirmed in the presence of the patient using the patient's
wristband.
Issue #2: A second issue relates to who
can perform pre-administration identity checks, i.e., who
qualifies as a qualified health professional. One person
performing the check must be the transfusionist (only registered nurses
or physicians trained in transfusion), but policies about the second
professional vary between facilities.
For example, besides RNs and
physicians, some facilities allow the second person ("checker") to be a
licensed practical nurse (LPN/RPN) or perfusionist, whereas others allow
only RNs and physicians to be involved. In the UK
BCSH
guidelines
(C.5) states the following about the single person doing the identity
check can be a physician, registered nurse, or midwife:
The member of staff must be a doctor, or a
nurse holding current registration of the UKCC Professional Register
as a Registered General Nurse (RGN), Registered Sick Children's
Nurse (RSCN) or Registered Midwife (RM).
-
Regardless of who the health professionals are, whoever participates in the transfusion process must be
trained in blood
administration and assessed for competency.
Monitoring patients
Blood safety standards tend to provide general
guidance so as not to handcuff practitioners, and this applies to
monitoring patents being transfused. For example, CSTM
L3.11 states:
Before, during, and after transfusion, recipient vital signs shall be
monitored and documented.
Accordingly, facilities have different policies for when to
monitor transfused patients. Best practices typically specify that patients should be monitored closely for the
first
15 minutes and that it is advisable to transfuse slowly (50 mL/hr) for the
first 15 minutes, where possible. Regardless of when vital signs are
monitored, patients should be routinely checked on (visually monitored)
throughout a transfusion.
A review of best practices indicates that patient vital signs
are typically
assessed at these times:
- Start of the transfusion
- 15 minutes after the start of transfusion
- End of transfusion
In addition, to show the variety of practices,
some facilities also check vital signs
- Pretransfusion
- 30 minutes after the start of transfusion,
then hourly until the transfusion is completed
- 1 hour after the start of transfusion and
hourly until the transfusion is completed
- Post-transfusion (e.g., 30 mins. or 4 hrs.)
BCSH
guidelines
(E. The Care and Monitoring of Transfused Patients) are more explicit:
5 Vital signs (temperature, pulse and blood pressure) should
be measured and recorded before the start of each unit of blood or
blood component, and at the end of each transfusion episode.
6 Vital signs related to transfusion should be recorded separately
from routine observations and clearly dated to enable the
information to be retrieved later, if necessary. Routine
observations should be continued on unconscious patients in
operating theatres and ITU.
7 Temperature and pulse should be measured 15 min after the start of
each unit of blood or blood component.
8 Further observations during the transfusion of each unit of blood
or blood component are at the discretion of each clinical area and
need only be taken should the patient become unwell or show signs of
a transfusion reaction.
Documentation
Documentation of patient and donor identity
checks, vital signs, and other required transfusion data (discussed
above) is essential.
- Monitoring and documentation of vital signs needs to be
done for each blood component transfused.
It is preferable that clinical information on the
transfusion be kept in one place, since it will then be easy to track
and retrieve should this be required later, e.g., vital signs,
product and
transfusion data (transfusionist identity, donor unit no., time started,
etc.), and outcome
information.
See
this sample form:
This example includes is a place to record
additional information, such as patient
- informed consent for transfusion
exists
- education about possible adverse
events has been given
Informed consent
Although informed consent is beyond the scope of
this case, note that some facilities require clinical staff to confirm
that informed consent for transfusion has been obtained
- Before
sending transfusion requests
to the transfusion service laboratory, e.g.,
- Use physician's order forms with a box that
must be checked before the TM laboratory issues blood products
- When a release for blood products is ordered
by the clinical area, a flag pops up in the computer system
asking the person ordering if consent for blood transfusion has
been obtained
-
Before starting the transfusion
In emergencies where transfusion is urgent, such
requirements may be delayed until after the transfusion is started so
that treatment is not delayed.
Patient education
Instructing patients about possible adverse events is
a requirement of blood safety standards (see below). Some facilities use
a check box on the Transfusion Record Form (as above) to remind staff to
do this.
Standards and Regulations
Standards and regulations exist for administering transfusions. See these
sample Canadian Standards (not all inclusive):
CSTM
Standards (Z902-04 references as
superscripts)
L2.0 IDENTIFICATION
L2.1 Policies and procedures shall be established to ensure
continuity of unequivocal identification of the recipient and the blood
and blood product from the specimen collection through to transfusion
using a unique patient banding system. 11.3.1/11.3.2
L2.2 Immediately before transfusion and in the presence of
the recipient, the transfusionist shall confirm and document that all
identifying information linking the recipient and the blood and blood product
matches. 11.3.3
L2.3 Transfusion shall not be initiated if any discrepancy
is found in the identifying information until the discrepancy is resolved.
11.3.5
L2.4 The compatibility tag shall remain attached to the
blood and blood product at least until completion of the transfusion.
11.3.4
TRANSFUSION ADMINISTRATION
L3.11 Before, during, and after transfusion, recipient
vital signs shall be monitored and documented. The recipient
shall be monitored by qualified personnel for suspected adverse
reactions during and after the transfusion. If direct medical
monitoring is not possible after transfusion, the recipient or a
responsible caregiver shall be given instructions concerning
possible adverse reactions. 11.4.13/11.4.14
L5.0
TRANSFUSION DOCUMENTATION
L5.1 The following information shall be entered on the
recipient’s medical chart at the time of transfusion:
a. type of blood and blood product transfused
b. product identification number
c. start and finish date and time of transfusion
d. identity of the transfusionist.11.1.2.4
L5.2 A transfusion record shall be completed for each
transfusion including:
a. information on the compatibility tag
b. date and time of transfusion
c. identity of the transfusionist
d. any adverse reactions to the transfusion 11.1.2.3
The record, or a copy, shall become part of the recipient’s
medical record. 11.1.2.3/11.4.15
This Case
In this case two nurses confirmed the identity of patient HL
and his donor units,
instructed him on possible adverse reactions,
and took vital signs according to hospital protocols for the first FFP
transfusion.
However, for the second unit of FFP, an error
occurred. Vital signs
were not taken at the start of the second transfusion although the nurse planned to take them one hour
after the
start. The nurse incorrectly considered the monitoring of vital signs to
apply to the entire transfusion event, as opposed to each unit
transfused. As a result HL's vitals signs were not monitored between the
time of completion of the first FFP transfused and when he developed
severe chest pain, almost an hour later.
We can only speculate as to whether earlier monitoring could have
prevented his rapid deterioration and death.
Learning
Points
- Best practices and standards exist for
administering transfusions, related to identification, monitoring
and documentation, and other practices.
- Clinical personnel who administer
transfusions must
be trained in blood administration.
- Monitoring and documentation of vital signs
must be done for each blood component transfused.
Practical
Notes
- Transfusion Record forms can help transfusionists administer
blood safely by
- serving as job aids that identify what needs to be done
- providing documentation of the transfusion, e.g., identification
checks, vital signs, start and end times, personnel, etc.
*
If you have comments on this section, please contact Pat:
TraQ self study
questions
1.
According to blood safety standards, which of the following must be
documented?
- Vital signs before during, and after
transfusion
- Person or persons
performing patient identity checks
- Identity of person
beginning the transfusion (transfusionist)
- Date and time the transfusion was started and ended
- all of the above
2. Do
blood safety standards require that two health professionals
verify patient identity prior to transfusion?
3. When do
Canadian CSTM Standards specify that vital signs must be monitored?
4.
What do you think is the most important requirement for
professionals who administer transfusions?
MORE
DISCUSSION...
FURTHER
READING
References
Brunskill S, Doree C, A. Blest A, J.
Murdock J, M. Roberts M, and D. Watson D.
Bedside practice of blood transfusion - Where is the evidence?
(poster P17) Transfus Med October 2006 Oct;16(s1):32.
Linden J, Kaplan H.
Transfusion errors: causes and effects. Transfus Med Rev
1994(8):169–83.
Shulman IA, Saxena S, Ramer L.
Assessing blood administering practices. Arch Pathol Lab Med
1999;123(7):595–8.
CSTM
Standards for Hospital Transfusion Services, Version 2
Online resources
BCSH.
 The administration of blood and blood components and the management
of transfused patients
(1999)
Capital Health, Edmonton, Alberta:
Physician documentation of informed consent
CBBS e-network forum:
Canadian Blood Services: Informed
consent
Informed
Consent (TraQ Resource Library)
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