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
- Monitoring patients
- Standards and regulations
- This case
- Self study questions
- Further Reading
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.
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.
- 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
- 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.
In the UK the BCSH guidelines (C.5. Administration of Blood and Blood Components - Identity check of patient and unit of blood) - at the time of this case study was created - 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. 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: Who can perform pre-administration identity checks
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.
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
- 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 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.
Some sample forms includes is a place to record additional information, such as patient
- informed consent for transfusion exists
- education about possible adverse events has been given
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 requeststo 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.
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 to remind staff to do this.
Standards and regulations exist for administering transfusions. See these sample Canadian Standards (not all inclusive) and now updated:
CSTM Standards (Z902-04 references as superscripts)
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
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.220.127.116.11
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 18.104.22.168
The record, or a copy, shall become part of the recipient?s medical record. 22.214.171.124/11.4.15
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.
- 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.
- 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.
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?
- Part 1: Clinical uses of FFP
- Part 2. Compatibility requirements for plasma
- Part 3. Administering blood products <--You are here
- Part 4: Investigating adverse events
- Part 5. Reporting adverse events