This section will review best practices for administering blood transfusions with a focus on monitoring the patient before, during and after transfusion, a key part of this case. Several protocols critical to the transfusion process were discussed extensively in Case O-5 and will be only briefly reviewed here.
- Protocols for patient identification
- Monitoring patient
- Standards and regulations
- This case
- Self study questions
- Further reading
The following is an example of a best practice identification protocol (others may be equally valid).
If the patient is alert, ask the patient to state his or her name.
Verify the patient's wristband identification information (first and last names, hospital identification number or equivalent) is identical to that on the blood unit label.
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Verify that the blood product is not outdated.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.
Blood safety standards 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.
Although 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 at these times:
- 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.)
For another example, see Calgary Laboratory Services. Policies relating to transfusion of blood components and products.
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.
Standards and regulations exist for administering transfusions. See these sample Canadian Standards (not all inclusive):
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:
- type of blood and blood product transfused
- product identification number
- start and finish date and time of transfusion
- identity of the transfusionist.126.96.36.199
L5.2 A transfusion record shall be completed for each transfusion including:
- information on the compatibility tag
- date and time of transfusion
- identity of the transfusionist
- any adverse reactions to the transfusion 188.8.131.52
The record, or a copy, shall become part of the recipient's medical record. 184.108.40.206/11.4.15
In this case the nurse failed to monitor the transfused patient according to policies and procedures in the nursing manual.
Questioning on why established procedures were not followed was unproductive, although the nurse reported that:
- She was exhausted near the end of working a 12-hour shift for three days in a row and was not thinking clearly.
- She believed that, if she left, she would not have been replaced and would have further burdened her colleagues.
As required by blood safety standards, the facility had a quality system in place that established a non-punitive system in order to encourage reporting of both near misses and actual errors.
- Mancini ME. Performance improvement in transfusion medicine. What do nurses need and want? Arch Pathol Lab Med 1999;123(6):496�502.
- Moore SB, Mary L. Foss ML. Error management: theory and application in transfusion medicine at a tertiary-care institution. Arch Pathol Lab Med 2003;127(11):1517�22.
Nurse. Following an investigation (see Discussion � Parts 3 and 4) the nurse was scheduled to receive immediate re-training on administration of blood with ongoing competency assessment at regular intervals.
System. The incident was used as an incentive to refresh all transfusionists on the clinical unit and all clinical units in the facility on the standards/policies related to administration of blood. Once a system of competency assessment for transfusionists was in place (currently in the planning stage), these competencies would be covered in annual assessment.
Related issues are discussed in Parts 3 and 4.
- Best practices and standards exist for administering transfusions (identification, monitoring, documentation, and other practices).
- Staff who administer transfusions must be trained and assessed in blood administration.
- Monitoring and documenting vital signs must be done for each blood component transfused before, during, and after transfusion.
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
- Date and time the transfusion was started and ended
- all of the above
When do Canadian CSTM Standards specify that vital signs must be monitored?
Do you think that claiming exhaustion is a valid defense for failing to follow established policies and procedures?
- Part1: Administering blood products
- Part 2: Investigating adverse events
- Part 3: Responsibilities when scope of practice conflicts with protecting patient safety
- Part 4. Education for interdisciplinary healthcare teams
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.
Calgary Laboratory Services. Policies relating to transfusion of blood components and products
CBBS e-network forum:
- Guidance on the length of time a patient must be observed during the start of a transfusion
- Monitoring vital signs during and after blood transfusion - revisited
Mancini ME. Performance improvement in transfusion medicine. What do nurses need and want? Arch Pathol Lab Med 1999;123(6):496�502.
Moore SB, Mary L. Foss ML. Error management: theory and application in transfusion medicine at a tertiary-care institution. Arch Pathol Lab Med 2003;127(11):1517�22.
Protocol for Administering Blood (SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST)
Shulman IA, Saxena S, Ramer L. Assessing blood administering practices. Arch Pathol Lab Med 1999;123(7):595�8.