KEMH/PMH PATHOLOGY CSU
HMF:0900
A/0
28/04/2000
Authorised by: Dr L Marshall
Haematology
KING EDWARD MEMORIAL HOSPITAL FOR WOMEN
AND PRINCESS MARGARET HOSPITAL FOR CHILDREN
TRANSFUSION REACTION REPORT FORM
___________________________________________________
PATIENT IDENTIFICATION
LABEL
________________________________________________
Ward
________________________
Consultant
________________________
Registrar
________________________
RMO
________________________
Reaction Date: ___________ Time:________
Diagnosis/Reason for transfusion: ____________________________________________________________
Component (Whole blood, etc) _______________________________ Volume given: __________________
Donation number of offending unit(s):
SYMPTOMS:
__________
Please fill in
All boxes
YES NO

Pyrexia ________C
Chills/Rigors
Urticaria
Tachycardia
Chest pain
________________
________________
________________
________________
________________
________________




Nausea/Vomiting
Dyspnoea
Lumbar Pain
Burning around vein
Hypotension




Haemoglobinuria
Excessive Bleeding
Jaundice
Shock




x
Other symptoms: ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------.
Treatment given: ---------------------------------------------------------------------------------------------------------------Result:
---------------------------------------------------------------------------------------------------------------
Previous Transfusion: _________________________
Reactions: __________________________________
Pregnancies:
Known Antibodies: ___________________________
_________________________
Date: _______________ Time: ________________
BLOOD BANK REPORT:
Request received:
Clerical labelling error:
Pre-transfusion sample blood group
Post-transfusion sample blood group
Medical Officer’s
Signature: __________________________________
Date:______________
___________________
____________________
____________________
Time:__________________
Antibody screen: _____DAT____
Antibody screen: _____DAT____
Investigation of blood bag and all units previously given:
Bag No.
Blood Group
Compatibility
Pre-trans
Post-transfusion serum – jaundice or haemaglobinaemia:
Urine:
D:\116101881.doc
Post-trans
DAT
Patient’s cells
against plasma
(if available)