NATIONAL NURSING AUDIT MINISTRY OF HEALTH MALAYSIA

ELEMENT 5: CONTINUUM OF CARE

5.4 5.4 BLOOD/BLOOD COMPONENTBLOOD/BLOOD COMPONENT TRANSFUSIONTRANSFUSION

1. INTRODUCTION

Blood transfusion if used correctly can save life and improve health. However,

there are risks associated with blood transfusion. The biggest risk associated

with transfusion is due to human error. These errors can lead to complications,

which can be serious and life threatening.

Nurses have to be competent in safely administrating a transfusion of

blood/blood products to an individual who has been identified as requiring this

procedure and their responsibility is to comply to the safety standards and

practices in order to prevent occurrence of adverse transfusion errors /

misadventures. This involves confirming pre-transfusion checks to ensure the

correct patient receives the correct blood. It also involves supporting and

monitoring the patient throughout the transfusion procedure, identifying and

responding promptly to indications of adverse reactions, completing relevant

documents and proper handling of used blood bags and other used equipment

on completion of infusion.

Nurses must also know the possible adverse events, which include febrile non-

haemolytic transfusion reaction, acute haemolytic transfusion reaction,

anaphylactic reaction, transfusion-associated graft-vs-host disease (GVHD) and

infection.

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2. OBJECTIVES

2.1 To ensure blood / blood components is safely administered to

patient.

2.2 To ensure reactions related to blood / blood component

transfusion is detected, reported and action taken immediately.

2.3. To ensure the nurse documents and complete the relevant records accurately.

2.4 To ensure that nurses exhibit the caring component when

administering blood / blood components to patients.

3. STANDARD

3.1. Nurses administer blood/blood component correctly to patient as

prescribed.

3.2 Nurses exhibit the caring component during the administration

of blood/blood component.

3.3 Nurses document accurately and completely into relevant

documents.

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4. CRITERIA

Structure Process Outcome

1. Each patient has current

legal written prescription

for blood/blood component

transfusion.

2. There is a Nursing

Operating Procedure

(NOP) for procedure for

blood/blood component

transfusion.

3 The nurse has

knowledge and skill on

transfusion practice is

competent in

administrating

blood/blood component

transfusion.

4. Nurse has knowledge of

transfusion reaction and

its measures

5. Consent for blood

transfusion.

6. GXM request form.

1. Greet patient

2. Confirm patient identification.

3. Confirm prescription.

4. Verify right patient and

blood/blood components together with the Doctor.

5. Complete pre-transfusion check list

- Verify screening.

- Verify expiry date.

6. Verify consent taken

7. Perform baseline monitoring.

8. Prime line with IV solution 0.9 Normal Saline. 9. Titrate flow rate

10. Observe for reactions

and take appropriate

measures.

11. Listen, respond to

patient/relative promptly

and politely.

12. Perform accurate

documentation

1. Patient is informed and aware of

possible risks. of the transfusion.

2. Patient receivedblood/blood product as prescribed.

3. Blood reaction are detected early and

appropriate measures taken timely

4. Documentation is

accurate and complete.

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Structure Process Outcome

7. Transfusion practice guideline MOH 2001/ PDN 2007.

8. PDN Check list.

9. Blood transfusion set

10. Blood card.

11. Patient progress notes/ temperature chart.

12. Intake / output chart

13. Observation chart

5. AUDIT GUIDE FOR BLOOD / BLOOD COMPONENT TRANSFUSION

5.1. INCLUSION CRITERIA

All patients in the ward who require blood / blood components

transfusion.

5.2 INSTRUMENT

Audit Form (E5 AF 5.4)

– one audit form for one observation

. 5.3 Methodology

5.3.1 Direct observation of blood / blood component transfusion

and also gathering information from documents.

5.3.2 Setting : Medical, Surgical and Orthopedic adult wards

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5.4. Sample Size

- 20 transfusions of blood/blood product from Specialist

Hospital and 10 for non-specialist hospital.

5.5. Time Frame

One month

6. DEFINITION OF OPERATIONAL TERMS

6.1. Written prescription :

6.1.1. Any legal orders of blood / blood components transfusion

Endorse in the patient’s medical records

6.2. Time limit for transfusion:

6.2.1 blood / blood component must be transfused within 30 minutes of removing the pack from refrigeration.

6.2.2 to start transfusion at 10 drops per minute. Nurse is to be at the patient’s bedside and to observe the patient for the first 15 minutes.

6.2.3 appropriate time frame per packi] whole blood : within 4 hoursii] packed cells : within 4 hoursiii] fresh frozen plasma : within 30 minutesiv] cryoprecipitate : within 30 minutesv] platelet concentrate : within 30 minutes

6.3. Verify right patient with blood / blood product

6.3.1. Confirm patient’s identity by 2 identifier

6.3.1.1. his name

i. Ask patient to confirm name

ii. Cross check with patient’s wrist band for name

and registration number

iii. Verify accuracy of identifier with patient’s medical

record.

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iv. Registration number

6.3.2. Confirm the right blood /blood product by verifying the

labels on the blood or blood product with patient’s blood

request form to ensure correct match:

i ] of blood / blood component

ii] ABO grouping & Rhesus factor correspond

iii] screening for HbsAg, HIV and VDRL done

iv] blood not expired

* No. [i] – [iv] to be verified together with the doctor

6.4. Assessment of patient pre-transfusion (baseline), during and post

transfusion vital signs and response/reaction:

6.4.1. Nurses need to determine the patient’s status prior to

administration by checking:

6.4.1.1 blood pressure,

6.4.1.2 pulse rate

6.4.1.3 temperature.

6.4.1.4 respiration

6.4.1.5 pain assessment

6.4.2 Initial monitoring 15 minutes upon commencement of blood transfusion and followed by hourly until completion

6.4.3 Reactions – e.g. chills, rigors, skin changes [rash], pyrexia, hypo / hypertension, respiratory distress, nausea and vomiting, renal shutdown [oliguria /anuria] abnormal bleeding [haematuria], anaphylaxis, pain [infusion site, chest pain, abdomen, loin].

6.5 Remedial action /appropriate measures:

– stop transfusion immediately, inform doctor urgently and

document measures taken

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6.6. Nurses when assessing the patient will exhibit the caring

component.

6.6.1 communicating well in a respectful manner.

6.6.2 giving the patient the privacy, dignity and modesty.

6.7 Right /proper documentation – implies accuracy and completeness

of documentation:

6.7.1 check list and blood card must be completed accurately

6.7.2 document date and time of administration must be

indicated in the intake and output chart / patient’s progress

notes /temperature chart [date & time of transfusion, blood

type, amount transfused]

6.7.3 document the evaluation of the patient

response to

the transfusion, whether any transfusion reactions

and appropriate measures taken.

6.7.4 document vital signs in observation chart.

6.7.5 document any identified adverse reaction to the blood

/blood product administered.

6.7.6 Document full name/cop, signature and date.

6.8 Transfusion errors include any following :

6.8.1 blood / blood component given not according toprescription

6.8.2 blood pack number / blood group / Rhesus Factor not corresponding to GXM request form.

6.8.3 name / registration number / identity card number on GXM request form not corresponding to patient’s case

notes

6.8.4 expired blood transfused

6.8.5 did not confirm screening for HbsAg, HIV and VDRL or non- Emergency transfusion

6.8.6 transfusion time not complying to appropriate time frame [for non-emergency cases]

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6.8.7 appropriate measures not taken when reactions / complications arise

6.8.8 baseline and regular monitoring of vital signs not done

6.8.9 inappropriate personnel [e.g. non-qualified staff. Appropriate personnel should have a diploma and above qualification to verify blood).

6.8.10 improper / incomplete documentation

* If any one of the errors above occur, it would be considered as transfusion error.*

7. Compliance of blood / blood components transfusion Safety

Audit .

Every step in the process must be performed.

a) Technical

- identify patient accordingly

- verify transfusion order.

- assess patient prior to administration

- takes the correct blood / blood product and administer

accurately – right blood and right patient.

- administer and ensure patient receives correct blood and

amount

b) Essence of Care (Soft Skills)

- greets patient

- explain and inform patient

- listen, responds promptly and politely to patient’s questions.

- exhibit caring component when assessing patient

c) Documentation

- document baseline vital signs and subsequence readings

- document blood /blood component administered – blood

number, amount, date, time and signature

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- document adverse reactions identified if any

- document appropriate measures taken if adverse reactions

Identified.

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8. AUDIT FORM

NATIONAL NURSING AUDIT MINISTRY OF

HEALTH MALAYSIA VERSION 1/08

ELEMENT 5 : CONTINUUM OF CARE

TOPIC : 5.4 BLOOD AND BLOOD COMPONENT

TRANSFUSION

DATE : 1.11.08

DOCUMENT NO : E5 AF 5.4  PAGE No. 1/3

 

1. STANDARD:

1.1. Nurses administer blood/blood component correctly to patient as

prescribed.

1.2 Nurses exhibit the caring component during the administration

of blood/blood component.

1.3 Nurses document accurately and completely into relevant

documents.

.

2. OBJECTIVES

2.1 To ensure blood / blood components is safely administered to

patients.

2.2 To ensure reactions related to blood / blood component

transfusion is detected, reported and action taken immediately.

2.3 To ensure the nurse documents and completes the relevant records accurately.

2.4 To ensure that nurses exhibit the caring component when

administering blood / blood components to patients.

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Date of Audit :………………………………….

Locality :…………………………………………

Auditors : 1. ……………………………………

2. ……………………………………

N.B. Instructions For Auditors

1. To tick [√] at appropriate column.

2. Item 1.11 is not rated if no specific nursing measures required.

S/N ITEM SOURCE OF INFORMATION

YES NO N/A

1 TECHNICAL

1.1 Confirm patient’s identification.

Ask patient his name or check bracelet.

1.2 Confirm prescription. Check doctor’s order in patient’s case notes.

1.3 Verify right blood / blood components with doctor.

Observe nurse & check written evidence.

1.4 Verify right blood / blood component for transfusion

Observe nurse and check written evidence.

1.5 Verify screening. Observe nurse and check written evidence.

1.6 Verify expiry date. Observe nurse and check written evidence.

1.7 Verify consent. Observe nurse and check written evidence

S/N ITEM SOURCE OF INFORMATION

YES NO N/A

1.8 Perform baseline monitoring. Observe nurse.

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1.9 Prime line with 0.9% saline Observe nurse

1.10 Titrate flow rate accordingly Observe nurse

1.11 Monitor patient within first minutes 15 of transfusion.

Observe nurse

1.12 Check vitals signs hourly till transfusion completes.

Observe nurse

1.13 Monitor time limit of transfusion.

Observe nurse / Ask patient / Check written evidence.

1.14 Identify reactions. Observe nurse / Ask patient / Check written evidence.

1.15 Take appropriate measures if required.

Observe nurse / Ask patient / Check written evidence.

2 DOCUMENTATION

2.1 Check for accuracy and completeness of documentation.

Observe nurse / Ask patient / Check written evidence.

3 SOFT SKILLS

3.1 The nurse explains to the patient prior to procedure:- purpose of blood

transfusion- Possible reactions that

may occur- When to call for

nurse(blood not flowing well, physiological needs, reactions)

- Duration of transfusion

Ask the patient.Observe nurse

3.2 Listen, responds promptly and politely to patient’s questions.

Observe nurse.Ask the patient

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AUDIT REPORT (Please [√] the appropriate box)

Conformance Non-Conformance

REMARKS

Auditor 1[Name and Signature]: ……………………………

Auditor 2 [Name and Signature]: ……………………………

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