Transfusion medicine handbook

1. Introduction

1.4 Haemovigilance

Blood components and fractionated products are biological in nature and carry inherent risks in respect of infection or reactions in the recipient. Common and, for the most part, minor reactions include febrile non-haemolytic and allergic transfusion reactions. A small number of problems account for the majority of difficulties and dangers associated with transfusion, for example delay in obtaining blood components needed urgently, transfusing blood components and fractionated products intended for another patient, over-transfusion leading to circulatory overload and pulmonary oedema, and transfusion-transmitted bacterial infections. Fortunately, the risk of transfusion-transmitted viral infections such as HIV, hepatitis B and hepatitis C is low when compared with other risks.

Clinical staff have the responsibility for recognising and reporting transfusion-related complications to the blood bank, NZBS Transfusion Medicine Specialist/Medical Officer or a Transfusion Nurse Specialist.

It is the task of NZBS and manufacturers of fractionated products to ensure that blood supply and transfusion practice are as safe as possible. Similarly, local hospital blood bank staff and the hospital transfusion committee should ensure that robust processes are in place to prevent errors and that adverse events are effectively investigated and reported.

 Some Common Causes of Problems

Most of the problems associated with transfusion that may cause delays and put patients at risk are poor communication, failure to follow documented procedures and inadequately trained staff. Frequently occurring problems are:

• Prescribing blood components and fractionated products that are not required by the patient or are not the most suitable treatment for the patient’s clinical condition.
• Failure to properly identify patients, leading to:
  • Incomplete or inaccurate completion of request forms or sample tube labels.
  • Improper collection of samples possibly leading to ‘wrong blood in tube’ (WBIT) incidents.
  • Transfusion of blood components and fractionated products that are intended for another patient.

• Delays caused by a failure to communicate accurately when and where blood components and fractionated products are needed.
• Failure to recognise and appropriately manage an adverse reaction occurring during transfusion.

Notification and Investigation of an Adverse Transfusion Reaction

NZBS has produced a form for notifying the blood bank of the occurrence of a transfusion reaction. Copies of the Adverse Transfusion Reaction (ATR) – Notification to Blood Bank form (111F009) (https://www.nzblood.co.nz/healthcare-professionals/transfusion-medicine/adverse-reaction-reporting-and-management/) are normally available in each ward or from the blood bank.

On the reverse side of this form are guidelines for the management of adverse transfusion reactions to assist clinical staff in the immediate care of the patient.

Haemovigilance Activities

NZBS is obliged to monitor the occurrence of adverse events during the transfusion process from vein-to-vein (i.e., from donation collection through to transfusion), in line with principles contained in the Council of Europe Guide to the Preparation, Use and Quality Assurance of Blood Components (https://www.edqm.eu/en/blood-guide) Donor adverse events, specimen labelling errors, blood bank errors, bedside checking errors and transfusion reactions are all examples of activities which fall under the umbrella of ‘haemovigilance’ and for which NZBS has systems in place to capture information.

In turn, the National Haemovigilance Programme (https://www.nzblood.co.nz/healthcare-professionals/haemovigilance-programme/) specifically receives notification of adverse events that occur during, or as a result of, transfusion. All New Zealand hospitals and blood banks participate in the programme, reporting any transfusion-related adverse events, near-misses and errors involving patients in the hospitals they serve. NZBS also works with hospitals to ensure that adverse events are appropriately managed and reported in a timely manner.

Transfusion is a complex process involving many different staff groups in the hospital. Any failure in the transfusion chain has the potential to cause significant harm to, or even death of, patients. Therefore all personnel involved in the transfusion process should be vigilant and report any untoward events that they may observe.

Further information about the nature of adverse effects of transfusion and how they should be reported to NZBS can be found in Chapter 7:Adverse Events in Transfusion

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Last updated: April 2023. Previously part of 111G122 – Transfusion Medicine Handbook 3^rd Edition

NZBS Reference: 111G01701