Right blood, right patient, right time RCN guidance for ... · Around 3.4 million blood components are transfused every year in the UK.Blood transfusion is a safe process that saves

R O Y A L C O L L E G E O F N U R S I N G

Right blood,right patient,right time

RCN guidance for improving

transfusion practice

Acknowledgements

We would like to thank everyone who reviewedRight blood, right patient, right time.RCN guidance for improving transfusion practice.

Authors

Alexandra Gray,Programme Manager, Effective Use of BloodGroup, Scottish National Blood TransfusionService, Edinburgh. Member of the RCN BloodTransfusion Steering Committee.

Jennifer Illingworth,Transfusion Liaison Nurse, Hospital LiaisonTeam, National Blood Service, Newcastle.Member of the RCN Blood Transfusion SteeringCommittee.

The Transfusion process section was adapted, withpermission, from the Scottish National BloodTransfusion Service Better Blood Transfusioncontinuing education programme – Level 1 safetransfusion practice materials.

Published by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN

© 2005 Royal College of Nursing. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in anyform or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the Publishers or a licence permittingrestricted copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP. This publication may not be lent, resold,hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it is published, without the prior consentof the Publishers.

Introduction 1

1. Transfusion process 3

2. The role of the nurse in thetransfusion process 7

3. The role of the transfusion practitioner 7

4. References 8

Contents


1

Introduction

Around 3.4 million blood components aretransfused every year in the UK. Blood transfusionis a safe process that saves lives and improves thequality of life in a large range of clinical conditions.But there are a number of risks associated withtransfusion as with any other clinical intervention.

Right blood, right patient, right time. RCN guidancefor improving transfusion practice sets out pragmaticadvice for nurses in the administration of red bloodcells and plasma components (fresh frozen plasmaand cryoprecipitate and platelets) in acute hospitalcare. The guidance is not wholly evidence-based butbuilt on recommendations to improve the safety ofblood ordering and administration from currentnational guidelines and Serious Hazards ofTransfusion (SHOT) reports (SHOT, 2005; SHOT,2003; BCSH, 1999; DH, 1999; DH, 2002; SHOT, 2002).

The British Committee for Standards inHaematology (BCSH), the four UK-country healthdepartments and SHOT have all recommended thatevery health care practitioner involved in thetransfusion process should receive appropriateeducation (SHOT, 2003; BCSH, 1999; DH, 1999; DH,2002). The BCSH had already published their 1999guidelines Administration of blood and bloodcomponents and management of the transfusedpatient (BCSH, 1999).

More recently in 2003, SHOT recommended thathealth care staff should receive transfusionprocedures training and formally assessedcompetency that is recorded if they contribute tothe transfusion process (SHOT, 2003).

In February 2005, two EU Directives – 2002/98/ECand 2004/33/EC were transposed into UK lawthrough the Blood Safety and Quality Regulations2005 (Statutory Instrument 2005/50 and StatutoryInstrument 2005/1098). These regulations set thestandards for quality and safety for the collection,testing, processing, storage and distribution ofhuman blood components. There are two aspects ofthe regulations which directly impact onpractitioners involved in the clinical transfusion

process:

✦ traceability asserts that we must haveunambiguous evidence of the final fate of everyblood component issued from the transfusionservices, and that the record is kept for 30 years

✦ haemovigilance reporting requires that anyserious adverse event or serious adversereaction, which might lead to death or life-threatening, disabling or incapacitatingconditions for patients or which results in orprolongs hospitalisation or morbidity, must bereported to the UK interim competent authority,the Medicines and Healthcare productsRegulatory Authority (MHRA). The MHRA hasdeveloped an online reporting system, SABRE,to facilitate reporting of serious adverse eventsand reactions.Visit www.mhra.gov.uk

The UK Operational Implementation Group hasrecommended that unless training is undertakenfor clinical staff and all involved in the process it isunlikely that compliance will be achieved.Visitwww.transfusionguidelines.org.uk for furtherinformation.

Despite these initiatives transfusion errorscontinue to occur and recent audits of transfusionpractice in the UK have demonstrated that patientsare placed at risk (see Table 1; Gray, Buchanan,McClelland, 2003; RCP/NBS, 2003).

Table 1

Summary of UK TransfusionPractice Audit Results(Gray, Buchanan, McClelland, 2003;RCP/NBS, 2003)

✦ 18% of patients had no identification checkwhen the pre-transfusion sample was taken.

✦ 11% of blood components collected had nopatient minimum data set check.

✦ 10% of patients were not wearing awristband during their transfusion.

✦ 47% of patients had no vital signs monitoredwithin the first 30 minutes of the transfusion.

Transfusion risks

SHOT, a voluntary and anonymised reportingscheme, highlights potential transfusion risks.It collects data on the serious consequences of thetransfusion of blood components in order to:

✦ educate users in transfusion hazards and theirprevention

✦ improve standards of hospital transfusionpractice

✦ inform policy in transfusion services

✦ aid the production of clinical guidelines on theuse of blood components.

Since 1996, when the SHOT reporting schemestarted, the number of adverse event cases analysedhas increased by 284%. The largest number ofserious adverse events reported, 70% of all reports,has been in the incorrect blood componenttransfused (IBCT) category (see Box 1), in which apatient receives a blood component which did notmeet the appropriate requirement or was intendedfor another patient. About half of these eventsinvolve more than one error in the transfusionprocess.

Of the 1832 IBOT events reported over 8 years, 247were ABO blood group incompatible transfusions.Six patients have died as a direct result of anincorrect transfusion and another fourteen deathsappeared to be related.

Ninety-two patients suffered major morbidity (e.g.an acute haemolytic reaction requiring admissionto an intensive care unit). SHOT also receivesreports of inappropriate transfusion wherebypatients are unnecessarily prescribed bloodcomponents on the basis of an erroneouslaboratory result (SHOT, 2004). These occur as aresult of errors during blood sampling ordiagnostic testing, or mis-communication ofhaematology results, and can result in majormorbidity or death.

Box 1

2

R I G H T B L O O D , R I G H T P A T I E N T , R I G H T T I M E

Typical SHOT IBCT errors (SHOT, 2004)

✦ The blood sample was drawn from thewrong patient.

✦ Patient details were recorded incorrectlyon the blood sample label or the bloodrequest form.

✦ The incorrect unit was collected from theblood refrigerator.

✦ The formal identity check at the patient’sbedside was omitted or performedincorrectly at the time of the administrationof the blood component.


3

The transfusionprocess

Every hospital must have policies and proceduresin place for every step in the blood transfusionprocess (BCSH, 1999). While it is a medicalresponsibility to prescribe blood components, thecompletion of the request form, the responsibilityfor taking a blood sample for pre-transfusiontesting, and the administration of the componentcan be delegated to a nurse or midwife with theappropriate training (BCSH, 1999).

Informing the patient

“Every patient has a fundamental legal and ethicalright to determine what happens to his or her ownbody.” (DH, 2001)

When you care for a patient who is about toundergo a blood transfusion, you should:

✦ inform the patient about the intendedtransfusion therapy, and give them theopportunity to discuss it and raise any concernsthat they may have

✦ check that the decision to transfuse is recordedin the patient case notes before administeringthe blood component.

Sampling

“Every patient who may require a transfusion duringan inpatient or day patient episode will wear anidentity band on which is recorded legibly thepatient’s correct minimum identification data.”(BCSH, 1999)

When you take a blood sample, you should:

✦ ask the patient to state their first name,surname, and date of birth to check that youhave the right patient before you draw thesample

✦ ask another member of staff, relative or carer toverify the patient identification details if thepatient is unable to do this, for example,because they are unconscious or a child

✦ check the details against the patient’s identitywristband

✦ collect the required amount of blood into theappropriate sample tube. For example, thisshould be a minimum of 1 ml for neonates orvery young patients

✦ after you have drawn the blood sample andbefore you leave the patient, label thecompatibility sample tube clearly andaccurately with the patient details that you havetaken from the identity wristband

✦ sign the sample tube as the person drawing thesample

✦ check that the patient details on the sample tubeand request form correspond

✦ send the blood sample tube and request form tothe hospital transfusion laboratory (HTL) withthe appropriate request date and time.

1

Good practice advice

You should give all patients who may receive ablood transfusion a full explanation about theproposed treatment. Use the patient informationleaflets that are available from your local trust orBlood Transfusion Service.

For an example of leaflets available to users seewww.blood.co.uk/hospitals/library/pi

Collection

You should ensure that every blood componentcollected is checked against the patient’s minimumidentification data set (BCSH, 1999 and see Box 2).You should:

✦ check that the details on the blood collectionform, or local documentation, match theinformation on the patient’s wristband beforepassing the request to the person collecting theblood component

✦ check the patient’s identification details on theblood collection form, or local documentation,against the patient compatibility label on theblood component that you have just collected

✦ document the removal of the unit of blood byputting the date, time and signature of theperson removing it onto the blood fridgeregister or electronic release system

✦ inform the person who requested the bloodcomponent that it has arrived as soon as it isdelivered.

Box 2

4



When you are taking a blood sample you should:

✦ spell the patient’s name correctly andconsistently when you label the sample tubeand complete the request form

✦ give all unconscious patients a uniquepatient identification number and record thegender on the identification wristband as aminimum

✦ bleed only one patient at a time in order toreduce the risk of a patient identificationerror

✦ avoid taking the blood sample from the armthat is the infusion site because this mayresult in a diluted sample being sent foranalysis, or a spurious laboratory resultbeing obtained

✦ never pre-label the compatibility tube. Forexample, do not write the details on thesample label in advance of drawing theblood. Pre-labelling of sample tubes has beenidentified as a major cause of patientidentification errors that can lead to fataltransfusion reactions

✦ ensure that a valid reason for transfusion isprovided on the request form and record anypast relevant transfusion history and specialrequirements, such as CMV negative orirradiated components.

Patient minimum identificationdata set

✦ Name(s)

✦ Surname

✦ Address (in certain UK regions)

✦ Date of birth

✦ Hospital identity number


5

Pre-administration

The transfusion should begin as soon as possibleafter the blood has arrived in the clinical area(BCSH, 1999).You should check that the:

✦ patient understands the process and why thetransfusion is being given, and explain theprocedure fully

✦ blood component has been prescribedappropriately

✦ baseline observations of temperature, pulse andblood pressure are undertaken before startingthe transfusion of each unit of blood

✦ expiry date of the blood component is correct,and undertake a visual inspection for any signsof discoloration, clumping or leaks.

You also need to check if the patient has any specialrequirements, such as iradiated blood, and if theyrequire any concomitant drug, such as a diuretic.

Administration

You should ensure that every individual who needsa blood transfusion as an inpatient or day patienthas a final identity check (BCSH, 1999). Rememberto follow these action points:

✦ positively identify the patient (see Box 2) usingan open question “can you tell me your fullname and date of birth?”

✦ ask another member of staff, relative or carer toverify the patient identification details if thepatient is unable to do this if, for example, theyare unconscious or a child

✦ check these details against the patient’swristband for accuracy

✦ check that the blood group and the donationnumber on the compatibility label are identicalto the blood group and donation number on theblood component

✦ repeat this process for each componentadministered.


✦ If there are any discrepancies at this point, itis important that you do not proceed untilthey have been resolved.

✦ The environment in which the transfusion isconducted must provide adequate workingspace, and allow staff responsible for the finalpatient identity check to carry out anuninterrupted procedure.

✦ If you are interrupted in the checkingprocedure, you must start again.

✦ You must wash your hands, and follow yourlocal infection control policy when youadminister blood components.


If there are any discrepancies at this point, it isimportant that you do not proceed until theyhave been resolved.

Patient monitoringYou should ensure that every patient who receives atransfusion is monitored throughout the process(BCSH, 1999). Good record keeping is the mark of askilled and safe practitioner (NMC, 2002).Youshould:✦ ensure that the patient is in a setting where they

can be closely observed✦ advise and encourage your patient to notify you

immediately if they begin to feel anxious, or ifthey become aware of any adverse reactions suchas shivering, flushing, pain or shortness of breath

✦ monitor the patient’s temperature and pulse 15minutes after you begin the transfusion of eachunit, and record them on the transfusionobservation chart

✦ adjust the flow-rate so that you achieve the cor-rect infusion rate over the prescribed time period

✦ make additional observations indicated by thepatient’s condition and according to your localhospital policy

✦ continue routine observations throughout thetransfusion for an unconscious patient:temperature, pulse, blood pressure, and urinaryoutput

✦ document the start and finish times of each unit✦ record the volume of blood transfused on the

fluid balance chart, or 24-hour chart✦ document the donation number, component

type, and date transfused of each bloodcomponent transfused in the patient’s case notes.Follow your hospital policy for recording the finalfate of the transfused unit (UK Blood Safety &Quality Regulations, 2005)

If you suspect a transfusion reaction:✦ stop the transfusion and immediately inform the

doctor✦ if the reaction appears life-threatening, call the

resuscitation team✦ record the adverse event in the patient case notes✦ report the adverse event in accordance with your

hospital policy.

Technical aspects of administeringblood components(RCN Standards for Infusion Therapy(RCN, 2005))

✦ The size of the cannula depends on the size of thevein and the speed at which the blood is to betransfused.

✦ Blood components must be transfused through ablood administration set with an integral meshfilter (170–200µm pore size).

✦ In neonatal and paediatric practice, where smallvolume transfusions are being drawn into asyringe for transfusion, an appropriate filter mustbe used (Blood Transfusion Task Force, 2004).

✦ Only use infusion pumps if they are certified assuitable for blood components by themanufacturer, and an appropriate administrationset is used.You should ensure that the correctflow rate is set.

✦ Blood warmers can be used for bloodcomponents provided that they are specificallydesigned for that purpose, and include a visiblethermometer and audible alarm. Never improviseby warming blood components in hot water, in amicrowave or on the radiator.

✦ Do not add pharmaceuticals to bloodcomponents.

✦ Transfusion of each unit of red cells must becompleted no more than four hours after it hasbeen removed from controlled 4C storage. Redcell units that have been out of refrigeration andhave not been transfused within four hours mustbe returned to the blood bank. Rationale: onceout of the cold chain, the pack will slowly warmto ambient temperature, increasing the risk ofbacterial proliferation and red cell metabolism.Blood bank quality procedures must ensure thatall red cell units available for transfusion haveremained under approved storage conditions.

✦ Change the administration set at least every 12hours for a continuing transfusion and oncompletion of the transfusion.

✦ Discard the empty blood bags according to yourhospital policy.

6


Good practice adviceYou should monitor patients closely during thefirst 15 minutes of the blood transfusion becausesevere reactions can occur in the early stages ofthe process.


7

The role of thetransfusionpractitioner

The four UK health departments (2002) and SHOT(2004) have recommended that every trust shouldemploy a hospital transfusion practitioner, such asa specialist nurse or biomedical scientist. If thisrecommendation is followed, hospital transfusionpractitioners, working with lead consultants inblood transfusion and local blood bank managers,will be able to support clinical teams in the safeand effective use of blood. They will also be able topromote good transfusion practice actively by:

✦ endorsing national guidelines and evidence-based practice.

✦ facilitating transfusion audit and feedback(continuous improvement).

✦ facilitating incident reporting and follow up onany errors or near misses.

✦ encouraging education/training and increasingclinical competency.

✦ participating in the implementation of newtechnologies that enhance patient safety(Gray, Melchers, 2003; Dzik, 2003).

3The role of the

nurse in thetransfusion process

To promote and safeguard the patient’s interestsand wellbeing, the Nursing and Midwifery Counciladvises that “the administration of medicines is notsolely a mechanistic task to be performed in strictcompliance with the written prescription of amedical practitioner. It requires thought and theexercise of professional judgement” (NMC, 2002).The same criteria should apply to theadministration of blood components.

By becoming educated practitioners in the bloodtransfusion process nurses can demonstrate theirskill and competency in this field. This will lead toincreased compliance in high risk areas of thetransfusion process, such as patient identificationprocedures and record keeping. Further, it willimprove patient outcomes, and reduce clinical riskand error rates.

2

8


References

British Committee for Standards in HaematologyBlood Transfusion Task Force (1999) Guidelineson the administration of blood and bloodcomponents and the management of transfusedpatients. Transfusion Medicine, 9: 227–238.www.bcshguidelines.com

British Committee for Standards in HaematologyBlood Transfusion Task Force (2004)Transfusion guidelines for neonates and olderchildren. British Journal of Haematology, 124:433-453. www.bcshguidelines.com

Department of Health (1999) Better bloodtransfusion. London: DH. Management ExecutiveLetter 1999 (9).

Department of Health (2001) Good practice inconsent implementation guide: consent toexamination or treatment. London: DH. HealthService Circular 2001/023. www.dh.gov.uk

Department of Health (2002) Better bloodtransfusion. London: DH. Health ServicesCircular 2002/009 (England); NHSHDL(2003)19(Scotland); WHSC (2202) 137 (Wales)HSS(MD) 6/03 (North Ireland).

Dzik W H (2003) Transfusion safety in the hospital.Transfusion, 43: 1190-99.

Gray A, Buchanan S, McClelland, DBL (2003). Safeand effective transfusion in Scottish hospitals –the role of the transfusion nurse specialist.Unpublished report.

Gray A, Melchers R (2003) Transfusion nurses – theway forward (Serious hazards of transfusionannual report 2001–2002). Manchester: SHOT.www.shotuk.org

McClelland D B L (2001) Handbook of transfusionmedicine. London: The Stationery Office.www.transfusionguidelines.org.uk

Nursing and Midwifery Council (2002a) Standardsfor the records and record keeping. London: NMC.www.nmc-uk.org

Nursing and Midwifery Council (2002b) Guidelinesfor the administration of medicines. London:NMC. www.nmc-uk.org

Royal College of Nursing (2005) Standards forinfusion therapy, London: RCN. Publication code002 179

Royal College of Physicians (2003) Nationalcomparative audit of blood transfusion. London:RCP. ISBN 1 86016 027 1.

Serious Hazards of Transfusion (2002)Annual report 2000–2001. Manchester: SHOT.ISBN 0 9532 789 4 8. www.shotuk.org

Serious Hazards of Transfusion (2003)Annual report 2001–2002. Manchester: SHOT.ISBN 0 9532 789 5 6. www.shotuk.org

Serious Hazards of Transfusion (2004)Annual report 2003. Manchester: SHOT.ISBN 0 9532 789 6 4. www.shotuk.org

Serious Hazards of Transfusion (2005)Annual report 2004. Manchester: SHOT.ISBN 0 9532 789 7 2. www.shotuk.org

Scottish National Blood Transfusion Service (2000)Better blood transfusion continuing educationprogramme. Edinburgh: SNBTS. Adapted withpermission from Level 1 Safe transfusionpractice materials.www.learnbloodtransfusion.org.uk

Statutory Instrument (2005) UK blood safety andquality regulations, London: HMSO(SI nos: 50 and 1098)

Useful websites

National Blood Servicewww.blood.co.uk

Serious Hazards of Transfusionwww.shotuk.org

The British Committee for Standards inHaematology www.bcshguidelines.com

The Medicines and Healthcare products RegulatoryAgency (MHRA) www.mhra.gov.uk

UK Blood Transfusion and Tissue TransplantationGuidelines www.transfusionguidelines.org.uk

4

June 2004 , revised January 2006

Published by theRoyal College of Nursing20 Cavendish SquareLondonW1G 0RN

020 7409 3333

The RCN represents nurses and nursing,promotes excellence in practice and shapeshealth policies.

Publication code 002 306

Documents

Right blood, right patient, right time RCN guidance for ... · Around 3.4 million blood components are transfused every year in the UK.Blood transfusion is a safe process that saves