Adverse Reaction to Blood Transfusion
or Transfusion Event Notification
SITE:
ACH
FMC
PLC
RGH
SHC
Calgary Zone Rural Hospital (specify):
Affix addressograph imprint or patient label, or clearly print patient’s full
name (full surname, first name), date of birth, gender, Personal Health
Number or Medical Record Number.
Other (specify):
Instructions for Nursing Unit staff:
1. Document all adverse reactions to blood components/products on the patient health record.
2. Report all adverse reactions to the attending physician for follow-up.
3. Perform clerical checks by comparing the patient’s identification with the transfusion tag.
4. Report all transfusion events to the attending physician and to transfusion medicine. Complete a form for each patient if more than one was involved.
5. For further information see www.calgarylabservices.ca.
Implicated blood component/ product
Clerical check:
OK
Red cells
Plasma
Platelets
Other (specify)
Discrepancy (describe):
Volume Transfused:
Unit identification /product lot number:
Unit/product expiration date:
Date Transfused:
Time infusion started:
Time infusions stopped/completed:
Reaction date:
Reaction time:
Reported to TM: (date/time/technologist)
Premedication:
No
Given under Anesthesia:
Patient diagnosis:
Yes
Drug/Dose/Route:
No
Local/Regional
Hematology/BMT
Is the patient immune compromised?
General
Oncology
Yes
Medical
Surgical
Obstetrics/Gynecology
Trauma
Neonate
No
Clinical Symptoms (related to transfusion):
No clinical signs/symptoms
Nausea/vomiting
Oliguria
Diffuse Hemorrhage
Chills/Rigors
Dyspnea/Shortness of Breath
Hemoglobinuria
Jaundice
Shock
Temp:
Pre
C
Post
Pain:(specify)_
C
Resp:
Pre
Rash
Hypoxemia O2 sat:
Urticaria (hives)
Other (Specify) _
__________________
Post
BP:
Pre
Post
Pulse:
Was the transfusion of red cells discontinued as a result of the reaction?
Yes
No
Is a transfusion reaction investigation requested by the physician? (red cells only)
Yes
No
Was the unit transfused to patient other than the intended recipient?
Yes
No
Was an incorrect component/ product infused? (e.g. 5% instead of 25% albumin)
Yes
No
Is TRALI (Transfusion Related Acute Lung Injury) suspected**?
Yes
No
Is a serious reaction other than TRALI suspected or confirmed?
Yes
No
Was this a febrile reaction?
Yes
No
Pre
_______
Post
If the answer to ALL of these questions is NO, transfusion reaction investigation will NOT be performed. Complete and return this form to the
Laboratory.
If the answer to ANY of these questions is YES, a transfusion reaction investigation MUST be done.
For reactions to red cells:


For reactions to all other components/products:

In SCM order: Transfusion RXN Invest Level 1.
Collect a 6 mL mauve/lavender top tube from patient**. Label specimen with the patient’s
name and number as well as the RTSIS number that the patient is currently wearing.
 Send the patient specimen and the unit container to the Laboratory with this form.
Send the unit/product container to the laboratory with this form.
**Contact TM to determine specimen requirements for TRALI and investigation of components /products other than red cells.
Measures Taken:
None
Transfusion stopped
Transfusion restarted
Antipyretics
Antibiotics
Other (specify)_
______
Nurse/physician reporting reaction:
TM2034
20150827
Vasopressors
Analgesics
Antihistamines
Steriods
Diuretics
– Effective?
Supplementary O2
ICU required
Chest X-ray
Blood Culture
Mechanical ventilation
Duration
Name of person completing report: