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Policies & Online Forms

Revised Blood Transfusion

Effective Date: July 19, 2021

Background:
The Blood Transfusion Record is a paper form used when blood transfusion documentation does not occur through the Blood Product Administration Module (BPAM) in MiChart. Examples of when/where the paper form is used include:

  • MiChart downtime
  • OR and some procedure areas
  • Massive transfusion events

The current paper form was reviewed by Transfusion Medicine and a Sentinel Event Review Group after an incident where the wrong blood was transfused to a patient at our institution. Thankfully, no harm occurred in this event, but it presented the opportunity to PDCA and improve the quality of the form.

Features of Revised Form:

1. Readback steps defined using a U-CHECK format to improve visual checks between form and patient wristband and blood unit.

U-CHECK format.

2. Blood compatibility chart added to assist transfusionist with ABO compatibility.

Blood compatibility chart.

3. Transfusion reaction information moved to backside of the form (white and pink copies) and differences between transfusion reaction instructions for Inpatient/Outpatient versus OR and Procedure Areas separate out.

Differences between transfusion reaction instructions for Inpatient/Outpatient versus OR and Procedure Areas separate out.

Go-Live:

The revised forms will be placed into use Monday, 7/19/21. There will be several days where both forms may be in use, especially on emergency units stocked in the patient care area blood refrigerators. It is acceptable to use whichever form is attached to the blood bag.

Questions:

Robertson Davenport, MD, Medical Director Transfusion Medicine (pager 2982)
Terry Downs, Administrative Manager Transfusion Medicine (pager 61369)

Blood Product Codes and Descriptions in SOFT Laboratory Computer System

Chart of Plasma Derivatives

 

STORAGE of BLOOD/BLOOD COMPONENTS

Patient Care Units
Review the updated policy on responsibilities for storage of blood in blood refrigerators. » Policy

 

CIRCULARS of INFORMATION

Blood and Blood Components
Updated 2017

Table for Blood Products 

Use of Cellular Therapy Products

 

Autologous and Directed Donations, Preadmission Type and Screen, Transfusion Reaction

 

Form Number Source
Adult Blood Transfusion Clinical Guidelines 3/24/09 NA On-Line (pdf)
Transfusion Reaction Report PS 715 Blood Bank 6-6888 or On-line
Consent for Transfusion

2040700

 On-line
Refusal for Transfusion   On-Line
Post Transfusion Instructions POD-0271

On-Line Print two copies - One form to Patient and One to the Medical Record
Nursing Fast Fact Information for Obtaining and Transfusing Emergency Blood Rev date 1/20/09 Blood Bank 
Platelet Refractoriness Worksheet NA Transfusion & Apheresis Service or On-Line
Apheresis Consult Sheet NA Transfusion & Apheresis Service or On-Line
On-Call Transfusion Reaction Evaluation Form (Blood Bank House Officer Use only) NA Blood Bank or On-Line (pdf)
Booklet - Blood Transfusion Your Options IP-2059315/pp  On-Line
Preadmission Type and Screen - Blue Form 2042411 Blood Bank 6-6888 - Blue Form -On-Line form must add numbers manually. To be printed on blue paper
Preadmission Type and Screen - Pink Form   Blood Bank 6-6888 - Pink Form On-Line to be printed on pink paper.
Preadmission Type and Screen Instructions   Instructions in pdf file
Therapeutic Phlebotomy Order   Form for printing pdf
Autologous Donation - Physician Request   Blood Bank 6-6900 or On-Line pdf
Autologous Donation - Patient Information   Blood Bank 6-6900 or On-Line pd
Red Cross Special Collection Form   Blood Bank 6-6900 or On-Line pdf
Directed Donation - Patient Information   Blood Bank 6-6900 or On-Line pdf
Directed Donation - Physician Order   Blood Bank 6-6900 or On-Line pdf New
List of Autologous and Directed Forms and Phone Numbers   Blood Bank 6-6900 or On-Line pdf

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