Safe Transfusion Practice

Question 1

What is the BSQR Act (2005)?

Answer 1

Blood Safety and Quality Regulations Act

• sets standards for quality and safety of human blood and blood components
• includes training, administration, traceability requirements and notification of adverse reactions and events
• governed by the Medical Health Care Regulatory Agency (MHRA)
• must comply with act 100% of time

Question 2

Patient Blood Management (PBM) is an evidence based multidisciplinary approach to optimising the care of patients who may need a blood transfusion. What does it include?

Answer 2

Patient and staff education
Active management of anaemia
Minimise the volume of blood samples taken
Use restrictive thresholds
One unit transfusion in non bleeding patients then reassess
Active management of abnormal haemostasis
Use alternatives to transfusion where appropriate
Surgical patients: detect and treat anaemia pre op, be aware of drug interactions that increase anaemia risk

Question 3

Transfusion incidents and reactions are reported to what 2 external agencies?

Answer 3

MHRA/SABRE - legal reporting system

SHOT - voluntary BUT required by CQC/NHSLA

Question 4

What is a never event?

Answer 4

Transfusion of ABO incompatible blood components

Question 5

What is the most common cause of death and major morbidity (with regards to transfusions)?

Answer 5

Transfusion associated circulatory overload (TACO)

Question 6

What were the highlights of the SHOT report 2016?

Answer 6

Human factor played a part in 87% of reports to SHOT
TACO = most common cause of death
Number of reports of delayed transfusion has increased
Missed specific requirements (irradiated blood products, CMV neg) continues to be leading cause of patients not receiving the correct components

Question 7

What are the indications for gamma irradiated blood components?

Answer 7

Patients treated with certain chemotherapy drugs e.g Alemtuzumab, Bendamustine, Fludarabine
Hodgkin’s disease - indefinitely from time of diagnosis
Intrauterine transfusions

Question 8

What do irradiated blood products reduce the risk of?

Answer 8

Graft vs host disease in at risk population

- destroys any T lymphocytes remaining in donated blood

Question 9

What are the indications for CMV seronegative blood components?

Answer 9

All pregnant mothers until establish labour
Intrauterine transfusion
Neonates

Question 10

What are the indications for HLA- matched platelets?

Answer 10

If patient has poor response to 2 or more platelet transfusions

Question 11

What are the indications for HbS negative RBCs?

Answer 11

Patients with sickle cell disease

Infants up to 1 year of age

Question 12

Where CMV status is unknown what should you assume?

Answer 12

The patient is CMV neg

Question 13

What is the irradiation indicator on the RADTAG labels?

Answer 13

If central dot white = not irradiated

If central dot blue = irradiated

Question 14

What does a group and save determine?

Answer 14

Patient’s blood group and rhesus status

Screens for atypical antibodies

Question 15

How long is a group and save valid for?

Answer 15

Maximum of 3 days

Question 16

How long does a group and save take?

Answer 16

Approximately 40 minutes

Question 17

Is blood issued with a group and save?

Answer 17

No

It is done if blood loss not anticipated, but maybe required if loss more than expected

Question 18

How many group and save samples are needed?

Answer 18

2 separate group and save results required before blood can be issued.

G&S sample 1 - results can be used from past 10 years
G&S sample 2 - must be current (max 3 days)

Question 19

What should you do if you are unsure if you need to take 1 or 2 samples from patient for G&S?

Answer 19

Phone/ bleep blood bank

Question 20

What is a crossmatch?

Answer 20

Physically mixing patient’s blood with donor’s blood to see if immune reaction occurs

Question 21

In general should second sample for GandS be taken at same or different time as first?

Answer 21

Different time

BUT in life threatening emergency (major haemorrhage) two samples may be drawn from same venepuncture provided: two trained and competent members or staff independently positively identify patient, witness the blood drawn and independently label and sign the sample and request forms

Question 22

The decision to transfuse should be based on…

Answer 22

Careful assessment of patient’s clinical state and must be justified as essential to prevent major morbidity and mortality

Question 23

What general principles should prescribing clinicians follow when deciding to transfuse?

Answer 23

Consider all alternatives before prescribing blood products
Discuss risk and benefits
Provide written patient information leaflets
Document consent on prescription or in medical notes
Inform patient they can no longer be blood donor

Question 24

All patients should be assessed for their risk of TACO. This should include…

Answer 24

Consideration of their weight
Review med history (especially cardiac and respiratory)
Review of fluid balance
Consider infusion rates
Consider need for diuretics
Consider one unit transfusions 
Review of patient in between units 
Add to fluid balance chart 

This assessment should be documented in patient notes

Question 25

What falls under cardiac part of TACO checklist?

Answer 25

Does patient have diagnosis of HF, severe AS or moderate to severe LVD?
Is the patient on a regular diuretic?

Question 26

What fall under the respiratory part of TACO assessment?

Answer 26

Is the patient known to have pulmonary oedema?

Doe the patient have respiratory symptoms of undiagnosed cause?

Question 27

What fall under the fluid part of TACO assessment?

Answer 27

Is the fluid balance clinically significantly positive?
Is the patient on concomitant fluids or have they in past 24 hours?
Is there peripheral oedema?

Question 28

If the answer is yes to any of the 3 main TACO criteria, what should be done?

Answer 28

Review the need for transfusion - do benefits outweighed risk?
Can the transfusion be safely deferred until the issue can be investigated, treated or resolved?

Consider body weight dosing for red cells especially if low body weight
Transfusion one unit and review symptoms
Measure fluid balance
Consider prophylactic diuretic
Monitor vital signs closely, including O2 sats

Question 29

Each unit transfused is an independent clinical decision. True or false?

Answer 29

True
Need to clinically re assess your patient after each unit is transfused - is patient still symptomatic, is further transfusion appropriate?

Question 30

Should you only order one unit at a time for non bleeding patients?

Answer 30

Yes

Question 31

Most near miss incorrect blood component transfused were due to what? (SHOT 2017)

Answer 31

Wrong blood in tube errors

Question 32

What measures should be taken to avoid sampling errors?

Answer 32

The person who takes the blood must positively identify the patient by checking the wrist band and wherever possible speak to the patient

Blood sample tubes must be clearly labelled with patient full name, hospital number/NHS number, DOB, date and time sample taken and signed by person taking blood

One patient should be bled at a time and tubes should be labelled after they are filled with blood at patient bedside

No discrepancies allowed between info on request form and on tubes

Question 33

What is on the request form?

Answer 33

ID of patient 
Blood group if known
Previous transfusions
Antibodies if known 
Reason for request and which components
How much, when is it needed and where 
Special requirements 
Operation date and type 
Consultant - samples not accepted without this

Question 34

When collecting emergency blood, do you need any documentation?

Answer 34

No
Speak to blood bank before you take it as may not be suitable for everybody - they need patient name and hospital number
Must be scanned out from fridge

Question 35

What should you know when collecting emergency blood?

Answer 35

Whether you need emergency O neg or emergency O positive blood

If I doubt take the emergency O negative

Question 36

When are the critical points for patient ID in the transfusion process?

Answer 36

Patient admission and identity band application
Taking blood sample and labelling at patients bedside
Collection of correct blood product from storage fridge
Pre administration checks at patient bedside

Question 37

What is the administration procedure?

Answer 37

1) prepare all equipment
2) two qualified members of staff check the compatibility/traceability label with the blood bag label and the pathology report form
3) both staff sign the pathology report form when checks completed
4) check transfusion prescription chart against blood products
5) check to patient’s: first name, surname, DOB, hospital number match the patient details on the blood product
6) ask patient to tell you their: full name and DOB, check against patient ID wristband
7) both staff sign prescription chart to confirm checks have been performed at patient bedside

Question 38

What should be done with traceability label?

Answer 38

Must be retained on ward for collection
Must not be torn in half
Must be completed, this includes emergency blood
This is a legal requirement (records have to be kept for 30 years)

Question 39

Can patients refuse blood products?

Answer 39

If they have filled out an advanced decision to refuse specified medical treatment.

For any adult patient refusing blood/blood products that has capacity to make decisions but does not have an advanced directive, they have to fill out refusal of blood products - consent form 5

Question 40

When reporting severe transfusion reactions, what should you do?

Answer 40

Send to lab:
Remains of donation unit
Repeat Gand save samples
FBC, clotting and chemistry 
First urine sample post reaction
Blood culture if considering sepsis
Complete transfusion reaction form 
Complete Datix incident report

Question 41

Can night time transfusions occur?

Answer 41

Where there is clear indication and as long as night staffing is sufficient to permit transfusion according to required standard e.g

• adequate pre transfusion assessment
• observations are 15 mins after start of each component
• regular visual observations throughout
• education and competency