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Blood transfusion policy

1 Policy summary

This policy outlines the processes and procedures required for blood transfusions in St John’s hospice. It is applicable to all patients considered for a blood transfusion and all colleagues involved in the procedure. The policy is important as it adheres to the national standards and governance required for this interventional treatment. This policy is read in conjunction with the service level agreement (SLA) with Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust (DBTH).

2 Introduction

This policy is adapted from the Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust’s (DBTHFT) policies for blood transfusions available at Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, as DBTHFT are our blood product provider:

  • Blood transfusion policy: pre-administration (PAT/T 80)
  • Blood transfusion policy: blood components, Blood Products and transfusion reactions (PAT/T 81)
  • Blood transfusion policy: Jehovah’s Witnesses and refusal of transfusion (PAT/T 84)

The transfusion of blood and blood components is a potentially dangerous treatment. It involves a complex sequence of events to ensure that the right patient receives the right blood and strict procedures need to be in place, with checks at each stage (National Patient Safety Agency, 2006).

Errors in the requesting, supply and administration of blood leads to significant risks to patients. Errors either in the collection or labelling of the sample for blood grouping and compatibility testing, or in the laboratory, or the failure of the final pre-transfusion checks account for a number of patient deaths in the UK each year. The incidence of “wrong blood” episodes has changed little over several decades. Variation in the practice of the administration of blood is becoming increasingly evident from audit, both local and national, and from the serious hazards of transfusion (SHOT) reports. Consequently, the trust is committed to the use of competency assessment of all colleagues involved in the transfusion process and is committed to the actions set by National Patient Safety Agency (NPSA) (2006) Safety notice 14 (right patient, right blood).

Blood transfusions in palliative care are not given routinely, but to treat problematic symptoms of anaemia, the cause of which in palliative patients is often multifactorial. Symptom burden to the patient, such as weakness, fatigue and breathlessness and likely benefit of the transfusion are important when deciding whether to transfuse or not (Waddell et al. 2011).

According to a Cochrane review (Preston et al. 2012) a third of patients with advance cancer do not benefit from blood transfusions and the duration is often short for those who do. In fact, there is the potential for harm to patients at the end of life due to fluid overload. The National Comparative Audit of Red Blood Cell Transfusion in Hospices (Neoh et al. 2018) also highlights the complications of transfusions, to include acute transfusion reactions, bacteria contamination and transfusion associated circulatory overload (TACO). The blood transfusion authorisation form (WPR26565) now contains a mandatory assessment checklist for TACO. Palliative patients are particularly vulnerable, therefore, decision to transfuse must be undertaken responsibly and on an individual basis.

This policy is based on recognised guidelines and provides the trust with local procedures for the ordering and administration of blood products and the management of transfused patients.

2.1 Relevant contacts

  • Blood bank, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust (DBTH): 01302 366 666 (contact via Doncaster Royal Infirmary switchboard)
  • Transfusion practitioner: 01302 366 666 (contact via Doncaster Royal Infirmary switchboard)
  • Consultant haematologist: 01302 366 666 (contact via Doncaster and Bassetlaw Teaching Hospital switchboard)

3 Purpose

The purpose of this policy is to provide guidance, minimise risk and set out organisational arrangements for implementing best practice in relation to blood transfusions within the hospice setting. It sets out the procedures to which colleagues should adhere when requesting and administering a blood transfusion to patients.

4 Scope

The policy applies to all colleagues within St John’s Hospice involved in the process of blood transfusion, which includes prescribing, obtaining blood samples, collection, administering or returning blood and after care.

Other trust inpatient settings are not included in this policy as they do not administer blood transfusions.

For further information about responsibilities, accountabilities and duties of all employees, please see appendix A.

5 Procedure

Blood transfusions should only be administered in usual hospice working hours (Monday to Friday, 9am to 5pm) and when a doctor is on site. Blood transfusions are not to be administered out of hours or at weekend.

5.1 Quick guide

  1. Assess the clinical need for the transfusion consent.
  2. Blood transfusions are only administered within normal working hours Monday to Friday, between 9am to 5pm. They are not to be administered out of hours, bank holidays or weekends.
  3. Positive patient identification process strictly followed for sampling and administering transfusion.
  4. Two sample prior to transfusion rule.
  5. Venous access of patient prior to arranging the blood collection from blood bank.
  6. Strict rules for receipt of blood on the ward, once validated cool box open the transfusion should be started within 30 minutes of opening the box and the transfusion completed within 4 hours.
  7. Strict monitoring prior, throughout and post transfusion.
  8. Traceability and documentation.
  9. Retain the blood product bag for 24 hours post transfusion.

5.2 Consent

Patients consent must be obtained before any treatment is given.

Patients have the right to know about the treatment being offered and the available alternatives. This should be done in a timely and understandable manner.

It is essential to adhere to the trust policy for consent to examination care and treatment.

Patients must be given information regarding the nature and purpose of the treatment, risks or benefits and alternatives, including the option of no transfusion. This is the responsibility of a doctor; however, signed consent is not required.

It is helpful to provide patients with an information sheet outlining the risks and benefits of blood transfusion. For example, the NHS Blood and Transplant has produced a number of patient information leaflets; these are available to print off, as required, from NHS blood and transplant (download “Do I need a blood transfusion?”), or contact Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust’s transfusion practitioner.

Colleagues will ensure information about risks or benefits and alternatives to blood transfusion are provided in a format to meet the person’s individual requirements. Information sheets available from the NHS Blood and Transplant online to print off when needed.

If a patient, with capacity declines a transfusion the doctor in charge of the patient should be informed and any product on the ward immediately returned to the blood bank.

The following information will be documented in the patient’s electronic record using blood prescription sheet WPR26565:

  • the discussion with the patient (details of the information provided to the patient)
  • reason for transfusion (clinical and laboratory data)
  • the administration of the transfusion and any complications
  • the clinical outcome
  • consent or refusal to proceed

5.1.1 Patients who may lack mental capacity to consent

If there is any concern about the patient’s ability to give consent, then an assessment of their mental capacity should be undertaken. This should be recorded on the patients record on Mental Capacity Act 1 template (MCA1). If the person is assessed as lacking mental capacity to consent to the procedure and does not have a valid and applicable advance decision to refuse the treatment (ADRT), then a decision will need to be made in the patient’s best interests under the Mental Capacity Act (MCA) (2005). This should be recorded on the patients record on Mental Capacity Act 2 (MCA2).

If the patient has appointed someone to make decisions on their behalf in relation to their health and welfare under a registered lasting power of attorney (LPA), then consent should be sort from the appropriate attorneys. It is important to check the lasting power of attorney health and welfare document and check for restrictions.

Colleagues should refer to the Mental Capacity Act (2005) policy for further guidance.

5.3 Patient blood management

Good patient blood management (PBM) can be described as management of the patient at risk of transfusion to minimise the need for allogeneic transfusion.

Blood products should only be prescribed when the clinician is satisfied that the risk of not transfusing is likely to be greater than the risk of transfusing.

5.3.1 Questions to think about before prescribing a transfusion

  • Have you acted on an up-to-date result?
  • Have you reviewed the clinical condition of your patient?
  • Is your patient symptomatic?
  • Is the transfusion appropriate?
  • Is intervention required?
  • Is transfusion the only appropriate intervention?
  • Is your patient less than 50kg? Be aware there is an increased risk of transfusion associated circulatory overload (TACO).
  • What volume should be transfused? Guidelines recommend a one unit transfusion then review before prescribing further units for non-bleeding patients.
  • Are the blood products prescribed on blood prescription sheet “WPR26565”.
  • Have you documented in the electronic patient record why you made the decision to transfuse?

5.4 Prescribing blood products

Blood components can only be prescribed by a doctor or authorised non-medical colleagues, for example, nurse consultant in palliative care, who has undertaken the NHS Blood and Transplant non-medical authorisation of blood components course and competencies.

All colleagues prescribing must be aware of the risks or benefits of transfusion training, all clinicians prescribing blood products must have the appropriate training or competencies completed as identified by the National Protective Security Authority (NPSA) and follow both local and national guidelines.

The prescription for blood and blood products must be signed and dated by the prescribing clinician on the appropriate blood prescription form “WPR26565”.

It is essential that the prescription sheet contains the patient identification details:

  • surname
  • first name
  • date of birth
  • patient NHS number

The prescription must specify:

  • consent obtained
  • what components are to be transfused
  • date of transfusion
  • the volume or number of units to be transfused
  • the rate of transfusion for red cells is usually one and a half hours to two hours
  • transfusion must be completed within 4 hours of removal from the authorised blood product transit box
  • any other special instructions or requirements, for example, irradiated.
  • blood bank must be made aware of any special requirements.
  • requirement for any concomitant drugs
  • any adverse reactions

5.5 Requesting blood products

Blood can only be prescribed by a doctor or authorised non-medical colleagues, for example, midwife or nurse with the appropriate training or competencies completed.

All phone requests must be followed by a written request form. Failure to do so will result in a delay in blood product provision.

5.6 Positive identification of patients

Positive identification of the patient is essential and is based on:

  • direct questioning of the patient, by asking them to state their surname, first name and date of birth, this must always be done where the patient is judged capable of giving an accurate, reliable response, colleagues should never lead the patient; the answer yes is not sufficient identification
  • checking the details on the patient’s identification wristband match those on the request form (all patients undergoing a transfusion must have an identification band)
  • all patients must have a patient identification number and an identification wristband with this number, when additional details become available the blood bank must be informed, but details must not be changed mid-incident
  • no wristband, no transfusion

5.6 Venepuncture

Positive identification of the patient must occur prior to venepuncture or transfusion of blood and blood products.

5.6.1 Venepuncture

Samples to be taken by a member of colleagues with a valid competency in venepuncture.

All patients being sampled must be positively identified. Sample tubes should not be pre-labelled.

The collection of the blood sample from the patient into the sample tubes and the sample labelling should be performed as one continuous uninterrupted event, involving one patient and one trained and competent healthcare worker only, samples to be labelled at the bedside using information taken from the patients’ identification wristband.

5.6.1.1 First sample

This can be an historical sample for example less than 7 days old or taken on the same day as the second sample.

5.6.1.2 Second sample
  • Must be a separate venepuncture event with new patient identification checks performed.
  • Must be sent to the laboratory site which will perform the blood issue. Ideally this would be performed by a different colleague, but this is not mandatory.
5.6.1.3 General principles

This national recommendation is based on the evidence from:

  • the best studies as referenced in British Society for Haematology guidelines for pre-transfusion compatibility procedures in blood transfusion laboratories
  • national data from the incorrect blood component transfused (IBCT) and the near miss chapters in recent serious hazard of transfusion (SHOT) reports (Serious hazard of transfusion, 1996 to 2010): 386 cases of wrong blood in tube (WBIT) were reported as near misses
  • local data confirms an unacceptable number of wrong blood in tube cases among patients where it can be detected due to having a historical group on record

Those taking samples for transfusion need to understand that the second sample is required due to the possibility of inadequate patient identification and labelling errors which lead to an unacceptable risk of WBIT and potentially a never event. The two samples must be taken independently of one another. Incidents have reported of the two samples being taken at the same time and one “saved” to send to the transfusion laboratory at a later time with a false time of venepuncture, this is a severe breach of the rules and could result in a “never event” should this lead to the transfusion of ABO incompatible red cells.

5.6.2 The request form

The request form must be completed in full (addressograph labels may be used) and include:

  • full name, surname and forename
  • NHS number to be used, hospital numbers from other hospitals are not accepted
  • date of birth
  • patient’s location
  • consultant
  • number and type of blood products required
  • date and time required
  • patient’s diagnosis or clinical details
  • reason for the request (clinical indication) including most recent haemoglobin and, or platelet count if applicable, include date tested
  • any special requirements (for example, Irradiated)
  • date and time bled
  • gender
  • requestor’s name and signature
  • the request form should be signed by the person drawing the sample
  • date of last transfusion
  • any known antibodies
  • if pregnant within the last 6 months and D-negative, please state the dates and doses of any prophylactic anti-D immunoglobulin administered during this pregnancy

5.6.3 The sample

  • Addressograph labels must not be used.
  • The patient must be positively identified at the time a sample is taken.
  • The sample tube must be labelled immediately after the blood has been taken (at the patient’s bedside); sample tubes must not be pre-labelled.

The sample tube must be labelled with the following:

  • full name, surname and forename
  • NHS number, hospital numbers from other hospitals are not acceptable
  • date of birth
  • gender
  • signature of personal taking the blood sample
  • ward or clinical area
  • date sample taken
  • time sample taken

5.7 Collection of blood products

Good documentation of the blood audit trail is mandatory and a legal requirement.

Before collection, ensure the patient is ready to start the transfusion, baseline observations taken and has patent venous access.

Ward colleagues arrange for blood products to be collected from the blood bank at Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust using the trust morning transport shuttle or approved taxi.

Ward colleagues to contact a member of colleagues at the blood bank and advise transport arranged to collect blood product, ensuring appropriate clinical information is available relating to patient’s name, NHS number and product requested.

5.8 Receipt of blood products on the ward

On arrival in the ward the blood must be immediately handed to the person responsible for administering the transfusion and not left in the nurses’ office or treatment room.

Blood should arrive in a validated cool storage box; this box must be sealed. The blood may remain in the validated cool storage box for no more than 2 hours. Once the validated cool storage box is opened the blood transfusion must be started within 30 minutes and transfused within 4 hours of removal from the validated cool storage box. Note, blood must not be stored in the ward drug or domestic fridges.

5.9 Returning blood products to blood bank

Blood and blood products should be transfused as soon as possible after delivery to the inpatient unit (see section 5.8) for example, within 30 minutes of removal from the validated cool storage box.

If after collection of the blood a problem arises which prevents immediate transfusion, the unit must be returned to the blood bank within 2 hours of collection and the blood bank colleagues informed (if in a validated cool storage box).

5.10 Administration of blood products

5.10.1 Key points

Final check must be conducted next to the patient by a trained and competent licensed healthcare professional who also administers the component including:

  • patients receiving a transfusion must be positively identified, all patient core identifiers on the patient’s identification wristband must match the details on the blood component label
  • all blood components must be administered using a blood administration set with integral mesh filter
  • transfusion should be commenced within 30 minutes of opening the temperature-controlled box and completed within 4 hours of leaving temperature controlled storage box

5.10.2 Colleagues responsible

Blood components are excluded from the current legal definition of medicinal products and the requirement for prescription by a registered medical practitioner, or a non-medical prescriber who has undertaken the designated NHSBT training course but are viewed as medicines for administration purposes. Blood components must only be administered by a licensed professional such as doctor (GMC (General Medical Council) registered), or a nurse holding current registration of the NMC (Nursing and Midwifery Council) professional register as a registered general nurse (RGN), who have had training in administering blood transfusions.

5.10.3 Receipt of blood products in the clinical area

  • The integrity of the pack by checking for leaks at the port or seams.
  • Evidence of haemolysis in the plasma or at the interface between red cells and plasma.
  • Evidence of unusual discoloration or turbidity.
  • The presence of large clots.

5.10.4 Responsibility for the identify check of the patient and the blood product, the final bedside check

Although two colleagues will be involved in the checking procedure, it is recommended that one member of colleague should be responsible for carrying out the identity check of the patient and the unit of blood at the patient’s bedside.

The member of colleague must be a doctor or a nurse holding current registration of the General Medical Council or The Nursing and Midwifery Council professional register as a registered general nurse (RGN).

Positive identification of the patient, the final bedside check.

Note, only the labelled blood product and the patient’s identity band are to be used as part of the final bedside check, not a compatibility form or prescription sheet.

This is essential and is based on tag and bag, tag and wristband checks:

  • direct questioning of the patient by asking their surname, first name and date of birth in the case of patients who are judged capable of giving an accurate reliable response
  • checking the details on the patient’s identity band is mandatory even if the patient can give their identity.
  • check the details on the patient’s wristband match the blood tag label:
    • the surname
    • first name
    • gender
    • date of birth
    • unique identification number must be identical with the blood tag label attached to the blood component
  • check the blood tag label is attached to the correct bag by checking the donation number, product type and blood group of both matches

Any discrepancies identified by these checks should be reported to the blood bank immediately and the transfusion delayed until clarification of any point is made.

The transfusion of blood and blood components should begin as soon as possible.

The prescription sheet must be readily available during the transfusion. The report must then be filed in the electronic patient record following completion.

5.10.5 Traceability

On completion of these checks colleagues must sign the blood transfusion compatibility report form, the peel off sticker from the blood tag label (which is then attached to the prescription sheet “WPR26565” and the blood tag for return to blood bank.

The start and finish time of the transfusion must be recorded on the blood prescription sheet “WPR26565”.

The completed detachable blood tag must be returned to blood bank immediately following transfusion to enable full traceability and ensure the trust fulfils its legal requirements as defined by BSQR 2005. The return of the tags is mandatory.

The efficacy or outcome or benefit of this transfusion must be recorded in the patient’s notes.

5.9.6 Spillage

Where a spillage of blood or blood products occurs, refer to the blood and body fluid spillage procedure.

5.11 Technical aspects of the administration of blood products

5.11.1 Giving sets

Adhere to strict aseptic techniques when handling blood or blood components. Refer to the aseptic non-touch technique procedure.

Blood products should be transfused through a sterile giving set designed for the procedure.

Filter size 170 to 200-micron filter is required.

Drugs must not be added to blood products under any circumstances

5.11.2 Red cells

Electronic infusion pumps may damage blood cells and should not be used for administration of red cells unless the manufacturers have verified them as safe to use for this purpose and colleagues have been trained in their use.

Only 1 unit of red cells can be transfused per day within St John’s Hospice, therefore to prevent bacterial growth a new giving set must be used after each transfusion. Always follow manufacturers guidelines. If a patient is acutely unwell and requires more than one unit of blood per day, transfer to the acute hospital is required. For safety reasons: only one patient per day may receive a blood transfusion within St John’s Hospice (see section 5.12.4).

Start transfusion as soon as the unit is received from Blood Bank.

Each unit of blood must be used within a maximum of four hours from leaving blood bank fridge or validated blood storage box, usually red cells are transfused over 2 to 3 hours.

Flushing through the remainder of the blood in the line with Sodium Chloride 0.9% is not recommended.

All blood products are leucocyte depleted.

Usually supplied as packed red cells in additive solution (SAGM).

5.10.3 Cannula

A 20-gauge cannula is the minimum size required for transfusion. The size of cannula chosen can affect the speed at which the blood can be transfused.

5.10.4 Drugs

Drugs must never be added to blood and products under any circumstances. Drugs must not be administered through the same cannula when transfusion of blood or blood products is in progress.

5.10.5 Disposal of blood bags

On completion of the transfusion the empty bag must be retained for a period of 24 hours and then discarded via the offensive hygiene waste for example, yellow bag with black stripes if there is no evidence of a transfusion reaction.

The empty bag will be stored in the designated sluice area in the nominated and labelled container. The nurse in charge will ensure appropriate disposal following the 24-hour period.

5.12 Care and monitoring of patients

5.12.1 Key points

Observations must be undertaken for every unit transfused. Minimum monitoring of the patient should include:

  • regular visual observation throughout the transfusion episode
  • pre-transfusion pulse (p), blood pressure (bp), temperature (t), respiratory rate (rr) and O2 saturation, to be taken no more than 60 minutes before starting transfusion
  • vital signs: a complete set of vital signs should be taken 15 minutes after the start of each component transfusion for all patients
  • rapid transfusions: more frequent observations may be required, for example, rapid transfusion, or patients who are unable to voice their symptoms which would raise suspicion of a developing transfusion reaction, such transfusions are unlikely in the hospice and would require acute admission
  • possible transfusion reaction: if the patient shows signs or symptoms of a possible transfusion reaction, the vital signs must be monitored and recorded, and appropriate action taken (see section 5.12). Vital signs must continue to be monitored every 5 to 15 minutes depending on the severity of the reaction and until reaction has resolved or escalated to hospital
  • post transfusion checks: post transfusion observations must be taken and recorded not more than 60 minutes after the end of the component transfusion
  • patients should be observed during the subsequent 24 hours or, if discharged, counselled about the possibility of late adverse reactions, clinical areas should ensure that systems are in place to ensure patients have 24-hour access to clinical advice

5.12.2 Colleagues responsible

The member of colleagues responsible for the care and monitoring of the patient during the transfusion must be a nurse holding current registration of the Nursing and Midwifery Council professional register as a registered general nurse (RGN), or a doctor.

They must take charge of the patient during the transfusion and be responsible for ensuring that all care and monitoring of the patient is performed.

5.12.3 Observation of the patient

It should be stressed to the patient the importance of reporting any adverse effects that they may feel, including shivering, rashes, flushing, shortness of breath, pain in the extremities or in the loins.

Visual observation of the patient is often the best way of assessing the condition of the patient during transfusion. Transfusions should be given in clinical areas where patients can be readily observed by members of the clinical colleagues. Patients should be able to alert colleagues if they experience any adverse effects.

The start and finish time of the transfusion must be recorded on the peel off sticker from the blood tag which is attached to the blood prescription sheet “WPR26565”.

Vital signs, temperature, pulse, blood pressure, respirations and O2 saturation must be measured and recorded before the start of each unit of blood or blood component, and at the end of each transfusion episode.

All patients must be weighed before each unit transfused.

During the first 15 minutes of the transfusion of each unit the patient must be regularly observed (most reactions will occur in this time and will require immediate attention) and the patient’s vital signs must be monitored and recorded.

Further observations during the transfusion of each unit of blood or blood product need only be taken should the patient become unwell or show signs of a transfusion reaction or if advised by blood bank.

5.12.4 Completion of transfusion episode

  • If a further blood component unit is required: repeat the administration or identify check with each unit.
  • If no further units are prescribed: remove the blood administration set.
  • Ensure all transfusion documentation is completed, and the tag is returned immediately to blood bank: return any unused blood products to the blood bank.

5.13 Reporting adverse events or reactions following or during transfusion

5.13.1 Colleagues responsible for reporting adverse events or reactions

Initial treatment of an adverse transfusion reaction (ATR) is not dependent on classification but should be directed by symptoms and signs. Treatment of severe reactions should not be delayed until the results of investigations are available.

Patients should be asked to report symptoms which develop within 24 hours of completion of the transfusion.

5.13.2 Initial clinical assessment

Initial clinical assessment seeks to quickly identify those patients with serious or life-threatening reactions so that immediate treatment or resuscitation can be initiated.

5.13.2.1 Immediate management of adverse transfusion reaction

If a patient develops new symptoms or signs during a transfusion, this must be stopped temporarily, but venous access maintained. Identification details should be checked between the patient, their identity band and the compatibility label of the blood component. Perform visual inspection of the component and assess the patient with standard observations.

5.13.2.2 Mild adverse reactions

For patients with mild reactions, such as pyrexia (temperature of greater than 38C and a rise of 1C to 2C), and, or pruritus or rash but without other features, the transfusion may be continued with appropriate treatment and direct observation.

Patients with mild isolated febrile reactions may be treated with oral paracetamol (500mg to 1000mg in adults). Patients with mild allergic reactions may be managed by slowing the transfusion and treatment with an antihistamine.

  • If at any time a transfusion reaction is suspected, the doctor in charge of the patient should be contacted by the nurse responsible for the patient during the transfusion and should review the patient promptly.
  • Any adverse events should be recorded in the patient’s notes and logged on the blood prescription sheet “WPR26565”.
  • It is the doctor’s responsibility to ensure the adverse reaction is reported to blood bank.
  • it is the responsibility of blood bank colleagues to report the event to senior blood bank colleagues or the transfusion practitioner to enable external reporting to sabre (serious adverse blood reactions and events) and, or serious hazards of transfusion (SHOT) if appropriate
5.13.2.3 Standard observations

The patients pulse rate, blood pressure, temperature and respiratory rate should be monitored and abnormal clinical features such as fever, rashes or angioedema frequently assessed. A patient who has experienced a transfusion reaction should be observed directly until the clinical picture has improved

A mild reaction may be the early sign of a moderate or severe reaction. Do not ignore it.

5.13.2.4 Severe adverse reactions

Management is guided by rapid assessment of symptoms, clinical signs and severity of the reaction.

  • The transfusion must be stopped immediately.
  • The blood administration set should be changed, and venous access maintained using sodium chloride 0.9% running slowly to keep the vein open.
  • The doctor must be informed and must assess the patient.
  • Escalate to Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust via 999 ambulances (all patients with severe reaction).
  • A consultant haematologist must be informed, the responsible doctor in charge of the transfusion must do this
  • The reaction should be reported immediately to the blood bank. complete a transfusion reaction investigation sheet, follow the instructions carefully and return to the blood bank and the senior transfusion team below along with any remaining blood products which may have been involved in the reaction:
  • Whilst awaiting the ambulance: the vital signs should be monitored immediately, recorded, and appropriate action taken. vital signs must continue to be monitored every 5 to 15 minutes depending on severity of reaction and until the possible reaction has resolved. the patient should not be left alone, the doctor should remain with the patient.
  • The volume and colour of any urine passed should be recorded in the patients’ notes.
5.13.2.5 Anaphylaxis

Anaphylaxis must be treated with intramuscular adrenaline (epinephrine) according to Resus UK guidelines. Patients who are thrombocytopenic or who have deranged coagulation should also receive intramuscular adrenaline if they have an anaphylactic reaction

5.13.2.6 Hypotension

If hypotension occurs during the blood transfusion, medical assessment is required immediately. Dependent on the assessment, the transfusion may be stopped, and the patient escalated to Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust via 999. Procedure for blood product reactions should be followed (see section 5.13).

5.13.2.7 Febrile symptoms of moderate severity

If a patient develops sustained febrile symptoms or signs of moderate severity (temperature greater than 39C or a rise of greater than 2C and, or systemic symptoms such as chills, rigor, myalgia, nausea or vomiting), bacterial contamination or a haemolytic reaction should be considered.

5.13.2.8 Transfusion associated circulatory overload (TACO)

Pre-assessment of the patient will guide the clinician of the risk factors for a patient developing Transfusion associated circulatory overload (TACO), and a subsequent plan put in place. Patients should be monitored throughout the transfusion and for 24 hours after. Shortness of breath is a non-specific symptom, but all new or worsening shortness of breath should be assessed by the medical team. If clinically appropriate the patient should be weighed post transfusion to assist in diagnosis of transfusion associated circulatory overload. Transfusion associated circulatory overload is treated as a medical emergency and the patient should be transferred to Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust via 999.

  • Patient characteristics: may occur at any age, but characteristically age greater than 70 years.
  • Component: any.
  • Speed of onset: defined as occurring within 6 hours of transfusion.
  • Oxygen saturation: reduced.
  • Blood pressure: often raised.
  • Jugular venous pressure: raised.
  • Temperature usually: unchanged.
  • Full blood count: no specific changes.
  • Response to fluid: worsens.
  • Response to diuretics: improves.

5.13.3 Investigation of a suspected transfusion reaction

The completed form and samples must be sent immediately to the blood bank with the blood product bags and giving set.

Samples required:

  • group and save
  • FBC (full blood count)
  • U and E (urea and electrolytes)
  • LFT (liver function tests)
  • coagulation screen
  • blood cultures

The blood bank will report on its investigation as soon as possible.

No further transfusion of units currently cross-matched should be undertaken until the blood bank investigation is complete; this may be mitigated by the consultant haematologist depending on circumstances.

5.13.4 Documentation of adverse events or reactions

Any adverse events must be recorded in the patient’s notes and logged on the blood prescription sheet “WPR26565”. Complete an incident form (IR1) and ensure a copy is sent to the blood bank.

All adverse events related to blood or blood product transfusion will be reviewed by the hospital transfusion committee.

Serious adverse events must be reported to the Medicines and Healthcare Products Regulation Agency (MHRA) via Serious Adverse Blood Reactions and Events (SABRE) and to Serious Hazards of Transfusion (SHOT) via the blood bank.

Suspected cases of transfusion-transmitted infection must be reported immediately to the local transfusion centre via the blood bank.

5.14 Document of transfusions

Full documentation of transfusion is mandatory and a legal requirement.

5.14.1 Documentation in the patient’s notes

A complete record of the transfusion on the blood prescription sheet (WPR26565), must be scanned into the patient’s electronic record. The form must be completed with the following information:

  • start and finish time of the transfusion on the blood prescription sheet “WPR26565”
  • the indication for the transfusion
  • the type and number of blood products used
  • whether the desired effect was achieved
  • the occurrence and management of any adverse effect
  • the peel off sticker from the blood tag must be attached to the prescription sheet
  • the sheets used for nursing observations during the transfusion

5.14.2 Documentation to be returned to blood bank

The return of the tags is mandatory.

The completed detachable blood tag must be returned to blood bank immediately following transfusion to enable full traceability and ensure the trust fulfils its legal requirements as defined by BSQR 2005. The return of the tags is mandatory

5.15 Jehovah’s witness policy and patient or family refusal of blood transfusion policy

Some people may refuse blood transfusion for a variety of reasons, for example, Jehovah’s Witness. We need to ensure that individual’s beliefs or preferences are acknowledged and respected and that relevant information is provided for the management of these patients.

Jehovah’s Witnesses have definite objections to blood transfusions for both religious and medical reasons. Jehovah’s Witnesses rule out the transfusion of red cells, whole blood, fresh frozen plasma, platelets and white cells, pre-donation (PAD) and may refuse to donate bone marrow or stem cells. Anti-D immunoglobulin and cryoprecipitate may be accepted and should be offered where appropriate. However, this is not available in the hospice and would need to be explained to the patient. Following consent, contact with the Jehovah’s Witness Liaison team and transfer to Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust would need to be arranged.

The majority of Jehovah’s Witnesses carry a “no blood” card which is a form of an advance decision to refuse treatment (legally binding), absolutely refusing blood, which also releases clinicians from any liability arising from this refusal.

It is the responsibility of the patient or attending relative to make sure their decision is drawn to the attention of healthcare professionals. If a patient decides to refuse blood products this should be clearly noted in the electronic records. If an advance decision to refuse treatment is presented, consent should be requested, and a copy should be prominently placed in the patient’s records (communication and records).

If refusal is by a non-Jehovah’s Witness is based on fear of transfusion transmitted infection, the risks should be clearly explained.

Refusal of blood transfusion must be carefully documented in the patient’s medical notes by the consultant or most senior doctor present, with the reasons given together with date, time and signature. A Checklist is available in the Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust policy, blood transfusion policy: Jehovah’s Witnesses and refusal of transfusion (PAT/T 84).

5.15.1 Jehovah’s Witnesses Hospital Liaison team

Contact the Jehovah’s Witnesses Hospital Liaison Committee with regard to alternative care or to locate doctors experienced in the management of Jehovah’s Witnesses.

Hospital Information Services for Jehovah’s Witnesses IBSA House
The Ridgeway
London
NW7 1RN

6 Training implications

6.1 All colleagues, including all doctors, involved in the process of blood transfusion, which includes prescribing, obtaining a blood sample, collect, administering or returning blood.

  • How often should this be undertaken: annually, competence assessment every 2 years.
  • Length of training: 3 hours.
  • Delivery method: face to face or e-learning.
  • Training delivered by whom: e-learning on electronic staff record (ESR):
    • blood transfusion consent: doctors
    • essential transfusion practice: all
    • transfusion reactions: all
  • Where are the records of attendance held: electronic staff record system (ESR).

All members of colleagues involved in the process of blood transfusions, which include prescribing, obtaining a blood sample, collecting, administering or returning blood, must have completed training on blood transfusions and be assessed as competent.

National guidance (BCSH 2012) states update training may be performed using an e-learning package appropriate to role and undertake competency assessments every 2 years. All training will be recorded using electronic staff records and also held by their line manager.

Clinical lead and the clinical manager received additional training provided by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust regarding blood transfusions in order to practically assess the hospice nurses.

All training must be documented, and records retained. Colleagues will receive instruction and direction regarding blood transfusion from a number of sources:

  • policies and procedures manuals
  • line manager or clinical lead
  • training via NHS England e-learning
  • communication methods (for example, team brief or team meetings)

7 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

7.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

7.1.1 How this will be met

Patients who refuse transfusion where clinically indicated for example, Jehovah’s witnesses will have alternatives treatment options explained and offered as detailed above no other issues have been identified in relation to this policy

7.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all employees working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

7.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

10 References

11 Appendices

11.1 Appendix A Responsibilities, accountabilities and duties

11.1.1 Chief executive

The chief executive has overall responsibility for ensuring the trust meets its statutory and non-statutory obligations in respect of maintaining appropriate standards contained in this policy.

11.1.2 Medical colleagues

Medical colleagues are responsible for prescribing blood and blood products appropriate to the need of the patient and obtaining and administering consent. Medical colleagues must keep up to date with training regarding blood transfusions.

11.1.3 Nurse consultant or clinical lead, ward manager and ward sisters

The nurse consultant or clinical lead, ward manager and ward sister have the responsibility to implement this policy and assist in the monitoring and compliance with the standards contained in this policy.

Also to:

  • provide evidence that clinical colleagues can demonstrate competency and compliance with the content of this policy
  • keep accurate, up-to-date training records of colleagues Blood Transfusion training
  • nurse consultant or clinical lead, ward manager and ward sisters will attend additional training provided by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust regarding blood transfusions in order to practically assess the inpatient unit (IPU) nurses
  • ensure any incidents involving the use of blood and blood products is reported using the incident reporting processes (IR1) and investigated appropriately

11.1.4 All colleagues

It is the responsibility of all registered nurses and colleagues involved with the transfusion process to:

  • comply with the requirements of this policy regarding patient identification, which is essential for safe transfusion practice
  • maintain accurate records and complete documentation required for audit trail of the transfusion

11.2 Monitoring arrangements

11.2.1 Monitoring and review of transfusion process

  • How: hospice internal audit.
  • Who by: Hospital Transfusion Team, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust.
  • Reported to: Hospital Transfusion Committee.
  • Frequency: annual.

11.2.2 Compliance with policy re documentation and traceability

  • How: return of blood tags to blood bank.
  • Who by: blood bank staff.
  • Reported to: ward.
  • Frequency: each transfusion.

Document control

  • Version: 4.5.
  • Unique reference number: 358.
  • Approved by: clinical effectiveness group.
  • Date approved: 10 June 2025.
  • Name of originator or author: nurse consultant in specialist palliative care.
  • Name of responsible individual: chief nursing officer.
  • Date issued: 2 July 2025.
  • Review date: 31 July 2028
  • Target audience: all colleagues within St John’s Hospice involved in the transfusion process.

Page last reviewed: July 03, 2025
Next review due: July 03, 2026

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