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					                                MELBOURNE HEALTH                SURNAME                                                   URN                                                             MELBOURNE HEALTH                  SURNAME                                         URN

                        BLOOD PRODUCT                           GIVEN NAME                     DOB              GIVEN NAME
                                                                                                                                                                                    Transfusion Reaction
                                                                                                                                                                                                                            GIVEN NAME                  DOB         GIVEN NAME

                       PRESCRIPTION FORM                        ADDRESS                                                                                                                 Investigation                       ADDRESS

                  Ward:                                         SUBURB                  POSTCODE       TELEPHONE                                                                                                            SUBURB                 POSTCODE   TELEPHONE


                                                                                                                                BLOOD PRODUCT PRESCRIPTION FORM
                                                                                                                                                                  Tests Requested:
 Irradiated                            Renal              CMV negative                     Leukocyte filter
                                                                                                                                                                  From tests available:
                BLOOD PRODUCT
               Saline Flush/ Diuretic Infusion                             Administration                 Nurse                                                   (Repeat Group and Screen, Repeat Cross-match, Urinary Hb, Plasma Hb, DAT, M&C for patient and / or blood
  Date                                               M.O. Signature                                                                                               packs)
                    if required         Rate                                   Time                    Signature x 2
             (Document each in correct order)

                                                                                                                                                                  Requesting Clinician
                                                                                                                                                                  Signature:                                            Surname (Print):
                                                                                                                                                                  Pager No:                  OR Mobile No:                                 Date:
If your patient does not meet these criteria, consider carefully the need for these fresh
products and the risk they carry to your patient.                                                                                                                 Person Drawing Blood for the 7.5ml purple topped tube must complete the following
                                                                          See Guidelines Central on Intranet for more detail.
                                                                                                                                                                  I have checked the information on the sample label and the request form against the patient’s
Red Cells:                                                  Fresh frozen plasma (FFP):                                                                            ID wristband before leaving the patient, and verify this as correct by having signed, dated and
 Haemorrhage (> 1000mL)                                       Haemorrhage with INR > 1.5                                                                        timed the sample tube and this declaration.
 Anaemia – (Hb 70-100g/L with ongoing blood loss)             Haemorrhage & Pt. over anti-coagulated.
 Anaemia – (Hb 70-100g/L - S&S of impaired O2                 Pre-Surgery with INR > 1.5
    transport eg angina, cardiac disease)                      Other (specify):
 Severe anaemia (Hb < 70g/L)
 Bone marrow failure (Hb 80 – 100g/L)                                                                                                                            Signature:                                            Surname (Print):
 Other (specify):
                                                                                                                                                                  Ward:                       Date Collected:                         Time Collected:

Platelets:                                                  Cryoprecipitate:
 Thrombocytopaenia:                                         Haemorrhage with Fibrinogen deficiency (<1.0g/L),
   Bone marrow failure- Plt count <10 x 109L OR <20 x       Haemorrhage from trauma with Fibrinogen deficiency
       10 L with risk factors                                   (<1.0g/L)
     Bleeding                                                 Haemorrhage in acute DIC
     Invasive surgical procedure                            Other (specify):
 Other (specify):

Clinician confirmation: I have reviewed the NH&MRC/ASBT Guidelines and explained to the

patient / person legally responsible for the patient, the indications, the nature and the possible effects of
the transfusion.
Written information offered to patient:  Yes

Signature of Clinician:                          Surname Printed:                                    Date:
                                                                                                                                                                           TO BE FILED IN PATIENT’S MEDICAL RECORD ON COMPLETION OF INVESTIGATIONS
                            MELBOURNE HEALTH                                SURNAME                                               URN                               MELBOURNE HEALTH                          SURNAME                                                            URN

                                                                            GIVEN NAME                DOB              SEX                                                                                    GIVEN NAME                         DOB                  SEX

                      PROCESS ERROR &                                                                                                                           BLOOD PRODUCT
                                                                            ADDRESS                                                                                                                           ADDRESS
                      ADVERSE REACTION                                                                                                                         PRESCRIPTION FORM
                                                                            SUBURB            POSTCODE       TELEPHONE                                                                                        SUBURB                    POSTCODE          TELEPHONE

Adverse Reaction Occurred?                Yes  No                                                                                     Registered Nurse Checklist for Administration of Blood Products                             (please tick)
                                                                                                                                                                                                                               UNIT          1           2           3           4
          Symptoms                    Possible Type Of Reaction                                       Action                                                                                                                   DATE
1. Chills, unexpected fever           For 1 or 2 of these 4 listed symptoms Slow transfusion. Observe patient more frequently           Identified and confirmed patient’s name and DOB verbally if patient responsive
   (> 38ºC or > 1.5ºC from            FNHTR [Febrile Non-Haemolytic         for signs of increasing or decreasing symptoms.
   baseline) nausea / vomiting,       Transfusion Reaction]                 Stop infusion and report to medical officer if              Identified patient’s name, date of birth, & UR on wristband, Blood Bank Issue
   headache.                                                                concerned.                                                  form - INV / H & blood product and all were correct.
2. Chills, unexpected fever           For 3 or 4 out of these 4 listed          Stop transfusion, maintain IV access, vital signs,      Checked blood group on ARCBS label and on patient label on the product &
   (>38ºC or > 1.5ºC from             symptoms                                  seek urgent medical advice. MO may advise               verified against Blood Bank Issue form – INV / H. and all were correct.
   baseline) nausea / vomiting,       Septic/Bacterial contamination            continuation of product after visual / physical
   headache.                                                                    examination of patient, return product bag to Blood     Checked donation number on both ARCBS label and patient label on the product
                                                                                Bank for culture. Document in medical history.          and verified against Blood Bank Issue form – INV / H and all were correct
3. Localised hives, rash, flushing,   Allergic                                  Stop transfusion, maintain IV access, vital signs,      Expiry date of product checked and was within dates.
    wheeze, hypotension                                                         seek medical advice.
                                                                                Document in medical history.                            Check patient was asked to report feeling unwell immediately to nursing staff
4. Chills, fever, back pain, ooze     Anaphylactic                              IMMEDIATE ACTION                                        DO NOT TRANSFUSE if any discrepancies are noted – seek clarification.
   from IV site, pain at insertion    ABO incompatibility /                     Stop transfusion, maintain IV access, vital signs,      You must sign the Blood Bank Issue form INV/H (issued with the product from the Blood Bank),
   site, hypotension,                 Haemolytic reaction                       seek medical advice URGENTLY.
   haemoglobinuria, patient has                                                                                                         Your signature signifies the above checking procedure has been completed.
                                                                                Return blood bag, specimens collected from patient
   feeling of impending doom                                                    & this form to Blood Bank. Notify haematology           Monitoring of a Patient Receiving Blood Products ALERTS!
                                                                                registrar. Document in medical history.                 Patients receiving blood products should be readily observed           Red blood cell transfusion should be commenced within 30
                                                                                                                                        throughout the transfusion.                                             minutes of removal from fridge or returned to blood bank.
                                                                                                                                        Vital Signs (Temp / Pulse / BP) must be measured:                      Red blood cells should be transfused within 4 hours.
5. Dyspnoea, productive cough,        Fluid Overload                            Sit patient upright, administer oxygen therapy,           Prior to each unit of blood / blood component.                      FFP transfuse over 15 - 30 mins.
   pink frothy sputum,                TRALI [Transfusion Related Acute          Seek medical advice, monitor vital signs,                 15 minutes post commencement of each unit of blood / blood          Platelets transfuse over 15 - 30 mins.
   hypertension, headache.            Lung Injury]                              Stop transfusion maintain IV line with n/saline               component at completion of each transfusion episode.             Cryoprecipitate transfuse over 15 - 30 mins.
                                                                                Document in medical history                               Observe patient for first 15 mins of transfusion for adverse        Do not infuse any other medications / fluids into same line
                                                                                                                                              events.                                                           as blood products.
                                                                                                                                          Initiate further observations if patient becomes unwell or          Administration set must have 170 - 220um inline filter.
Patient Diagnosis:                                                     Time Transfusion stopped:                                              shows signs of reaction.                                    All fresh blood components must be completed within 4 hours of being spiked

Donation Number:                                 Product Type:                             Date:                                                             DATE
Volume of affected Unit Transfused:                                    Was affected unit continued:       Yes       No                                     TIME
History of previous transfusion reaction:            Yes      No If Yes specify:                                                                      40

Medication (IV, IM, oral):  Yes  No If Yes specify (eg antibiotics, other meds):                                                                      39

SIGNS & SYMPTOMS (please tick)                                                                                                                          38    210
Minor                    Major                                                  Transportation / Administration errors                  TEMPERATURE           200
 Fever                   Tachycardia                                           Product lost/damaged in transport to ward             (blue)         37    190
 Chills                  Hypotension                                           Wrong unit signed off as having been given                            36    170
 Urticaria               Dyspnoea / Hypoxia                                    Incorrect use of giving set or filter                                       160
 Nausea / vomiting       Chest pain / Lumbar pain                              Incorrect rate of infusion                                            35    150
                                                                                                                                        Systolic              140
                          IV site pain / bleeding                               Transfusion record lost / not completed                               34    130
                          Haemoglobinuria                                       Patient ID band missing or incorrect                     |                  120
                                                                                                                                           |            33    110
CLINICAL REACTION - do bedside Clerical check (please tick):                                                                               |                  100
Patient ID correct:          Yes  No          Blood Unit correct:                           Yes       No                                Λ                  90
Transfusion report correct:  Yes  No          Previous transfusion:                         Yes       No                            Diastolic
Reported by:                                                                                                                                                   60
                                                                                                                                        HEART RATE
Print Surname:                                                Extension/Pager:                              Date:                                              50
                                                                                                                                        (red)                 40
Signature:                                                    Title:                                                                                           30
Clinical Outcome: Recovered?  Yes  No If No specify:                                                                                  RESPIRATION            20
                                                                                                                                           (red)              10
SPECIMENS (Send to Blood Bank ASAP)
  7.5mL Plain serum tube - BROWN                     7.5 mL EDTA tube - PURPLE (Group and Screen)                                     O2 Sat
  Blood cultures if appropriate                      Spot urine, immediate and 4hour post reaction (Urinary Haemoglobin)              Donation number
  Return all blood packs transfused or not with IV Giving Set to the Blood Bank                                                        Adverse Reaction Y/N

                  Return this document to the Blood Bank with blood specimens.                                                                      For further Information refer to Clinical Policy and Procedure Manual S21.6