FORM FRM1581/1.2
Effective: 26/11/15
Bacteriology Request Form For Investigation Of Suspected Contamination Of
Blood Components
Referring Hospital:
Donation number of implicated component:
Local NHSBT centre:
Name of duty NHSBT consultant contacted by the
hospital:
Patient details
Surname:
Forename:
DOB:
Details of implicated component
Type of blood component transfused
Red cells
FFP
Platelets
Other
Male/Female
Hospital number:
Details of transfusion reaction
Date and time transfusion of implicated
unit started:
Time from start of transfusion to onset of
symptoms:
Approximate volume transfused:
Details of indication for transfusion
Patient’s underlying diagnosis and
reason for transfusion:
Patient’s symptoms (please tick all that apply)
Pyrexia
Headache
Pain at iv site
Back pain
Chills or rigors
Tachycardia
Hypotension
Loin pain
Wheeze
Productive cough
Nausea or vomiting
Rash
Urticaria/hives
Breathlessness
Further details:
OBSERVATIONS BEFORE TRANSFUSION
TEMP
PULSE
BP
OBSERVATIONS AT TIME OF TRANSFUSION REACTION
TEMP
PULSE
BP
Management of transfusion reaction
Was the patient on antibiotics at the time of the
reaction?
YES
NO
If YES, which antibiotics:
Was the patient given antibiotics to treat the
reaction?
YES
NO
If YES, which antibiotics?
Were blood cultures taken from the patient?
YES
NO
If YES, where were they taken from:
Peripheral vein
Central line
Was the implicated unit cultured by your local
microbiology laboratory?
YES
NO
If YES, please forward these results when
available.
Name of person reporting the reaction:
Signature
Contact phone number:
Date:
Contact email address:
Notes
1. Any reaction which involves bacterial contamination as a differential diagnosis must be discussed as
soon as possible with the duty NHSBT consultant for patients, in case other components from the same
blood donation require recall. The Duty Consultant can be contacted via the NHSBT Hospital Services
Department at your local NHSBT centre
2. Return this form with the implicated unit(s) to your local NHSBT Hospital Services Department in the
labelled 3 litre biobottle provided specifically for this purpose. This will then be forwarded to the
National Bacteriology Laboratory at Colindale
3. The returned unit(s) must be adequately sealed with appropriate pack closure to prevent leakage and
contamination.
4. If possible unit(s) should be stored and transported at 2°C-8°C.
Enquiries should be directed to the Blood Components section of the National Bacteriology
Laboratory, NHSBT Colindale Centre on 020 8957 2959 or 020 8957 2962 or email
nbl@nhsbt.nhs.uk
(Template Version 07/10/08)
Cross-Referenced in Primary Document: SOP914
Page 1 of 1