King Fahad Specialist Hospital Departmental Policy and Procedure (DPP) - Issue of Blood and Blood Components PDF

King Fahad Specialist Hospital ‫ﻣــﺳــﺗــﺷـــﻔﻰ اﻟـﻣــﻠـك ﻓـﮭـــــد اﻟـﺗﺧـﺻــﺻـﻲ‬ Dammam ‫اﻟـــــدﻣــــــــﺎم‬ DEPARTMENTAL POLICY AND PROCEDURE (DPP...

King Fahad Specialist Hospital ‫ﻣــﺳــﺗــﺷـــﻔﻰ اﻟـﻣــﻠـك ﻓـﮭـــــد اﻟـﺗﺧـﺻــﺻـﻲ‬ Dammam ‫اﻟـــــدﻣــــــــﺎم‬ DEPARTMENTAL POLICY AND PROCEDURE (DPP) TITLE/DESCRIPTION: Issue of Blood and Blood Components CODE NO: EFFECTIVE DATE: APPLIES TO: DPP124 BBTM 101 All Blood Bank Technical Staff Refer To Media Lab STATEMENT OF PURPOSE Blood and its components shall be inspected at the time of issue. Blood Bank and Transfusion Medicine Lab results should be documented in a proper way and reported accordingly. RELATED REFERENCES 1. Technical Manual, latest Edition, Bethesda, MD: American Association of Blood Banks. 2. Standards for Blood Banks and Transfusion Services, latest Edition, American Association of Blood Banks. DEFINITIONS None POLICY 1. Patient MRN and name and family name shall be compared between the request, allocation sheet or release sheet during downtime, patient consent, and products before issuing Blood and blood components shall be inspected at the time of issue 2. Each unit to be issued shall have an attached unit tag 3. At the time a unit issued, there shall be a final check of transfusion service records on each unit of blood or blood component 4. Records discrepancies identified during issue shall be resolved before issuing Form No: 404/190 (Rev-2): July 2023 Departmental Policy and Procedure (DPP) – KFSH-D Page 1 of 11  King Fahad Specialist Hospital ‫ﻣــﺳــﺗــﺷـــﻔﻰ اﻟـﻣــﻠـك ﻓـﮭـــــد اﻟـﺗﺧـﺻــﺻـﻲ‬ Dammam ‫اﻟـــــدﻣــــــــﺎم‬ DEPARTMENTAL POLICY AND PROCEDURE (DPP) TITLE/DESCRIPTION: Issue of Blood and Blood Components CODE NO: EFFECTIVE DATE: APPLIES TO: DPP124 BBTM 101 All Blood Bank Technical Staff Refer To Media Lab Form No: 404/190 (Rev-2): July 2023 Departmental Policy and Procedure (DPP) – KFSH-D Page 2 of 11  King Fahad Specialist Hospital ‫ﻣــﺳــﺗــﺷـــﻔﻰ اﻟـﻣــﻠـك ﻓـﮭـــــد اﻟـﺗﺧـﺻــﺻـﻲ‬ Dammam ‫اﻟـــــدﻣــــــــﺎم‬ DEPARTMENTAL POLICY AND PROCEDURE (DPP) TITLE/DESCRIPTION: Issue of Blood and Blood Components CODE NO: EFFECTIVE DATE: APPLIES TO: DPP124 BBTM 101 All Blood Bank Technical Staff Refer To Media Lab PROCEDURE 1. Process Form No: 404/190 (Rev-2): July 2023 Departmental Policy and Procedure (DPP) – KFSH-D Page 1 of 11  King Fahad Specialist Hospital ‫ﻣــﺳــﺗــﺷـــﻔﻰ اﻟـﻣــﻠـك ﻓـﮭـــــد اﻟـﺗﺧـﺻــﺻـﻲ‬ Dammam ‫اﻟـــــدﻣــــــــﺎم‬ DEPARTMENTAL POLICY AND PROCEDURE (DPP) TITLE/DESCRIPTION: Issue of Blood and Blood Components CODE NO: EFFECTIVE DATE: APPLIES TO: DPP124 BBTM 101 All Blood Bank Technical Staff Refer To Media Lab Form No: 404/190 (Rev-2): July 2023 Departmental Policy and Procedure (DPP) – KFSH-D Page 2 of 11  King Fahad Specialist Hospital ‫ﻣــﺳــﺗــﺷـــﻔﻰ اﻟـﻣــﻠـك ﻓـﮭـــــد اﻟـﺗﺧـﺻــﺻـﻲ‬ Dammam ‫اﻟـــــدﻣــــــــﺎم‬ DEPARTMENTAL POLICY AND PROCEDURE (DPP) TITLE/DESCRIPTION: Issue of Blood and Blood Components CODE NO: EFFECTIVE DATE: APPLIES TO: DPP124 BBTM 101 All Blood Bank Technical Staff Refer To Media Lab 2. Step by step procedure 2.1 Receive the name and family name and medical record number documented on the consent from the collecting staff (SN3 or SN1 or OR technician) Form No: 404/190 (Rev-2): July 2023 Departmental Policy and Procedure (DPP) – KFSH-D Page 3 of 11  King Fahad Specialist Hospital ‫ﻣــﺳــﺗــﺷـــﻔﻰ اﻟـﻣــﻠـك ﻓـﮭـــــد اﻟـﺗﺧـﺻــﺻـﻲ‬ Dammam ‫اﻟـــــدﻣــــــــﺎم‬ DEPARTMENTAL POLICY AND PROCEDURE (DPP) TITLE/DESCRIPTION: Issue of Blood and Blood Components CODE NO: EFFECTIVE DATE: APPLIES TO: DPP124 BBTM 101 All Blood Bank Technical Staff Refer To Media Lab 2.2 Ensure the validity of the patient’s consent for blood and blood products and compare the patient’s full name and MRN on the blood request, release sheet (during downtime), and unit tag with the patient’s full name and MRN on the consent 2.3 Verify patient full name and MR# between the consent form, release sheet (during downtime only), and the request. 2.4 Collect the blood and blood components to be issued 2.5 Ensure that the product to be issued meet the special requirements as reflected on BBIS patient’s comments and BBIS transfusion protocol, FORM124/003- Blood Bank Transfusion Record or BBIS backup during downtime 2.5.1 Examples of special requirements include 2.5.1.1 Sickle cell negative blood for patients stipulated on IPP 124 BBTM 033 2.5.1.2 Antigen negative blood for patients with irregular antibodies 2.5.1.3 Patients who require irradiated blood as stipulated on IPP 124 BBTM 110 2.5.1.4 Neonatal requirements as stipulated on IPP BBTM 064 2.5.1.5 Additional requirements for patients with previous transfusion reactions 2.5.1.6 Patients with deviation from protocol, ensure that there is an existing approval by the BBTM Consultant as stipulated on IPP 124 BBTM 092 2.6 Perform inspection as per IPP 124 BBTM 128 2.7 Scan the MRN on the consent as much as possible, if not scannable, enter the MRN by typing and check against the consent that the correct MRN has been entered 2.8 Ensure that the transfusion location is the same as the requesting ward, if not, change the location on BBIS 2.9 Enter the name and ID Number of the collecting staff e.g Merriam/9315 2.10 Perform partial delivery for partial order or total delivery for full delivery 2.11 Print a delivery form from BBIS 2.12 Call out the following information from the allocation tag or release sheet (during Form No: 404/190 (Rev-2): July 2023 Departmental Policy and Procedure (DPP) – KFSH-D Page 4 of 11  King Fahad Specialist Hospital ‫ﻣــﺳــﺗــﺷـــﻔﻰ اﻟـﻣــﻠـك ﻓـﮭـــــد اﻟـﺗﺧـﺻــﺻـﻲ‬ Dammam ‫اﻟـــــدﻣــــــــﺎم‬ DEPARTMENTAL POLICY AND PROCEDURE (DPP) TITLE/DESCRIPTION: Issue of Blood and Blood Components CODE NO: EFFECTIVE DATE: APPLIES TO: DPP124 BBTM 101 All Blood Bank Technical Staff Refer To Media Lab downtime only) and ensure that the Collecting staff is confirming the patient and product Form No: 404/190 (Rev-2): July 2023 Departmental Policy and Procedure (DPP) – KFSH-D Page 5 of 11  King Fahad Specialist Hospital ‫ﻣــﺳــﺗــﺷـــﻔﻰ اﻟـﻣــﻠـك ﻓـﮭـــــد اﻟـﺗﺧـﺻــﺻـﻲ‬ Dammam ‫اﻟـــــدﻣــــــــﺎم‬ DEPARTMENTAL POLICY AND PROCEDURE (DPP) TITLE/DESCRIPTION: Issue of Blood and Blood Components CODE NO: EFFECTIVE DATE: APPLIES TO: DPP124 BBTM 101 All Blood Bank Technical Staff Refer To Media Lab information by reading back the information from the allocation paper or unit tag during downtime (which is already verified with the consent form, refer to 2.2) 2.12.1 The intended recipient’s full name and medical record number 2.12.2 The intended recipient’s ABO Group and Rh type 2.12.3 The product’s unit number, ABO Group and Rh type 2.12.4 The interpretation of crossmatch tests, if compatible 2.12.5 Special transfusion requirements such as premedication, issuing of anti-D etc. 2.12.6 The expiration date and time (pooled and thawed products) 2.13 Resolve the identified discrepancies and sign next to the rectified information, if applicable 2.14 Allow the nurse to read the same information from the physical product as stipulated under step 2.12 while you are checking on the allocation form 2.15 Call out the same information (step 2.12) again from the physical product while the collecting staff is checking the same information on the allocation tag 2.16 Give the post transfusion instructions (APP Management and Administration of blood and blood components- Attachment 3) for collecting staff that is collecting blood and blood components for OUTPATIENTS and ER patients that will be discharged immediately or shortly after transfusion and will not be under KFSHD care after transfusion 2.17 Allow the nurse to sign the delivery note or during downtime, sign the unit tag- FORM 124/006 and Blood Bank Release Sheet- FORM 124 BBTM 124 2.18 Allow the collecting staff to sign the unit tag and the release sheet during downtime 2.19 Document the date and time of issuing during downtime 2.20 Wait for the empty product bag and allocation form or during downtime FORM 124/006 to be returned to Blood Bank 2.21 Check that the product information on the bag match the product information on the product itself Form No: 404/190 (Rev-2): July 2023 Departmental Policy and Procedure (DPP) – KFSH-D Page 6 of 11  King Fahad Specialist Hospital ‫ﻣــﺳــﺗــﺷـــﻔﻰ اﻟـﻣــﻠـك ﻓـﮭـــــد اﻟـﺗﺧـﺻــﺻـﻲ‬ Dammam ‫اﻟـــــدﻣــــــــﺎم‬ DEPARTMENTAL POLICY AND PROCEDURE (DPP) TITLE/DESCRIPTION: Issue of Blood and Blood Components CODE NO: EFFECTIVE DATE: APPLIES TO: DPP124 BBTM 101 All Blood Bank Technical Staff Refer To Media Lab 2.22 Confirm transfusion on BBIS Form No: 404/190 (Rev-2): July 2023 Departmental Policy and Procedure (DPP) – KFSH-D Page 7 of 11  King Fahad Specialist Hospital ‫ﻣــﺳــﺗــﺷـــﻔﻰ اﻟـﻣــﻠـك ﻓـﮭـــــد اﻟـﺗﺧـﺻــﺻـﻲ‬ Dammam ‫اﻟـــــدﻣــــــــﺎم‬ DEPARTMENTAL POLICY AND PROCEDURE (DPP) TITLE/DESCRIPTION: Issue of Blood and Blood Components CODE NO: EFFECTIVE DATE: APPLIES TO: DPP124 BBTM 101 All Blood Bank Technical Staff Refer To Media Lab 2.23 On daily basis the senior technologist checks that transfusions were completed on BBIS. Incomplete transfusions are notified by e-mail to the relevant charge nurse for completion. 2.24 On monthly basis the percentage of completed transfusions is assessed and reported on the monthly report, unconfirmed transfusions are submitted to Nursing through electronic OVR RESPONSIBILITY Implementation of this IPP is the duty of all technical staff of Transfusion Medicine Service/Blood Bank, KFSH-Dammam. Blood Bank Supervisor will ensure that all staffs involved are following IPP accordingly. ATTACHMENTS 1. Form 124/006- Blood Bank Transfusion Report 2. Form 124/006 – Unit tag or blood compatibility report form 3. Form 124 BBTM. 124 - Blood bank work up and release log sheet 4. APP- Management and Administration of blood and blood components Attachment 3 SUMMARY OF CHANGES No changes Form No: 404/190 (Rev-2): July 2023 Departmental Policy and Procedure (DPP) – KFSH-D Page 8 of 11  King Fahad Specialist Hospital ‫ﻣــﺳــﺗــﺷـــﻔﻰ اﻟـﻣــﻠـك ﻓـﮭـــــد اﻟـﺗﺧـﺻــﺻـﻲ‬ Dammam ‫اﻟـــــدﻣــــــــﺎم‬ DEPARTMENTAL POLICY AND PROCEDURE (DPP) TITLE/DESCRIPTION: Issue of Blood and Blood Components CODE NO: EFFECTIVE DATE: APPLIES TO: DPP124 BBTM 101 All Blood Bank Technical Staff Refer To Media Lab Form No: 404/190 (Rev-2): July 2023 Departmental Policy and Procedure (DPP) – KFSH-D Page 9 of 11