Deviation in the Standard of Nursing Care During Administration of Blood Transfusions

Evaluate breaches in the standard of care when evaluating a Deviation in the Standard of Nursing Care During Administration of Blood Transfusions

Answer the following questions to find out if the standard of care was followed for your case.

  • Was an informed consent obtained prior to the blood transfusion?
    Yes
    No
    Answer unknown
    Why is this important?
    Prior to the administration of any blood product, an informed consent signed by the patient or a qualified representative of the patient is required, except in the cases of trauma or life saving situations.
    (2006) 20 ETRMDR 3 218-229

  • Were the indications for blood transfusion documented in the patient’s record? Why is this important?
    Answer this question
    
At the time of ordering, the physician needs to verify that the indications for the transfusion are clearly documented in the patient's medical record.

    (2006) 20 ETRMDR 3 218-229 



  • Was the clinician who administered the blood transfusion, qualified and registered? Why is this important?
    Answer this question
    
Safe transfusion practice is a complex, multi-step process. Only those qualified staff members possessing a current license to practice nursing as well as the training required by the healthcare facility, may administer a blood transfusion.

    (2007) 7 ENURED 4 215-227 



  • Was the facility’s policy and procedure for the pre-transfusion blood sampling followed? Why is this important?
    Answer this question
    
The nursing staff should follow hospital procedures for the collection of pre-transfusion samples and strictly adhere to all steps in the process.

    (1997) 66 EAORNJ 1 133-136,138,140-143 



  • Did the blood sample used to type and cross match the patient contain accurate information? Why is this important?
    Answer this question
    
A laboratory technologist needs to use the pre-transfusion blood sample to identify the ABO and Rh blood type of the patient whose name is on the blood sample label. If the pre-transfusion blood sample label is incomplete, incorrect or illegible, the potential for error is high.

    (1997) 66 EAORNJ 1 133-136,138,140-143 



  • Did the clinician perform and document the final patient identity check at the time of administration? Why is this important?
    Answer this question
    
Proper identification of the patient from sample collection through to blood administration, proper labeling of samples and products is essential.

    (2006) 20 ETRMDR 3 218-229 



  • Were incorrect blood components administered to the patient? Why is this important?
    Answer this question
    
Pre-transfusion verification is the last critical stage of patient identification with blood transfusions. The primary reason for ABO- or Rh-incompatible transfusions is the administration of properly labeled blood to the wrong patient.

    (2007) 7 ENURED 4 228-237 



  • Did the clinician ensure that the blood transfusion was completed within 4 hours? Why is this important?
    Answer this question
    
If a blood transfusion cannot be completed within four hours, those blood products must be discarded due to the possibility of bacterial growth in the blood products.

    (1997) 66 EAORNJ 1 133-136,138,140-143 



  • Did the clinician obtain and record the vital signs of the patient prior to the transfusion? Why is this important?
    Answer this question
    
After consents are signed and the blood is checked by the appropriate personnel, the nurse should take a complete set of vital signs for a baseline before starting the transfusion.

    (2006) 20 ETRMDR 3 218-229 



  • Were the vital signs of the patient obtained and documented 15 min after the initiation of blood transfusion, at one hour intervals throughout the transfusion and 30 minutes post transfusion? Why is this important?
    Answer this question
    
The patient’s vital signs need to be checked 15 minutes after starting the transfusion and then every hour during the blood transfusion according to hospital protocol, in order to check for a reaction to the blood.

    (2006) 20 ETRMDR 3 218-229 



  • Which of the following adverse reactions did the patient experience? Why is this important?
    Answer this question
    
Acute transfusion reactions present as adverse signs or symptoms during or within 24 hours of a blood transfusion. The most frequent reactions are fever, chills, pruritus, or urticaria, which may resolve without specific treatment or complications.

    (2006) 20 ETRMDR 3 218-229 



  • Which of the following symptoms were recognized and documented? Why is this important?
    Answer this question
    
For severe reactions, initiating immediate treatment is required to prevent the most serious sequelae, including death. Immediate nursing management comprises ceasing the transfusion and notifying the treating physician and the hospital blood bank. These patients usually require ICU support.

    (2010) 22 ECCNCN 2 179 



  • Which of the following corrective measures were initiated to alleviate the symptoms of the adverse reaction? Why is this important?
    Answer this question
    
Immediate nursing management comprises stopping the transfusion, re-performing the pre-transfusion checklist, documenting observations, providing immediate patient care and contacting the treating physician.

    (2006) 20 ETRMDR 3 218-229 



  • Did the blood bank screen the blood donors for blood-borne diseases? Why is this important?
    Answer this question
    
Despite continuous advances in blood donation screening, hepatitis B and C infection still poses a strong threat of transfusion-transmitted viral infection. Human immunodeficiency virus is an infectious agent whose effective transmissive properties pointed to the need to screen donors, screen donor blood and institute inactivation regimens.

    (2010) 38 AJPRME S 4 S468-S474 



  • Did the clinician document the details of the blood transfusion? Why is this important?
    Answer this question
    
Adequate documentation of the transfusion is essential. The patient's medical record must include the order for the transfusion, the blood component type issued, the donor unit number, the date and time of the transfusion, pre- and post transfusion vital signs, the amount of blood infused and the identification of the transfusionist. The patient must be observed during and after the transfusion for any adverse effects of the transfusion and the immediate outcome of the transfusion must be documented.

    (2006) 20 ETRMDR 3 218-229