Blood transfusions are the most common hospital procedure performed in the United States. Over the past ten years, the number of blood transfusions performed in the US
increased by over 126%¹¹ . Blood transfusions are now extremely prevalent in hospital settings throughout the US. Every two seconds someone in the United States needs blood, and over 30 million blood components are transfused each year² . Worryingly, 2 out of 8 of the most common hospital acquired conditions can occur during a blood transfusion (Air Embolism and Blood Incompatibility)¹² . Due to the prevalence of blood transfusions in the health care setting, it is crucial that health care providers understand the metrics and components of successful blood transfusion processes.

The internal processes for blood transfusions often involve multiple departments, a diverse mixture of staff, and multiple hand-off points. With so many diverse parties involved, the possibility for errors exists. In an effort to reduce the potential for errors the Joint Commission, along with several international organizations, recommend that health care providers measure the success (performance) of each step in the chain 14 . As such, they have developed a list of measurable items (These are measurable rates or percentages. The terms numerator/denominator refer to the components of the percentage [numerator/denominator]):

• Transfusion Consent – Comparing: [Numerator] the number of patients who received information about the risks, benefits and alternatives prior to the initial blood transfusion or the initial transfusion was deemed a medical emergency (Compared to) [Denominator] the total number of patients who received a transfusion of red blood cells, platelets, or plasma¹⁴.
  • Monitoring this percentage can help remind health care providers to discuss the risks and benefits of blood transfusion with patients whenever possible. This involves the patient in their health care service and any questions or worries should be answered prior to a transfusion.
• Red Blood Cell (RBC) Transfusion Indication – Comparing: [Numerator] The number of RBC units (bags) with pre-transfusion hemoglobin or hematocrit result and clinical indicationdocumented (Compared To) [Denominator] Number of Transfused Red blood Cell Units evaluated¹⁴.
  • The same measurement can be done with Plasma or Platelets in order to measure the usage and correct documentation of those procedures. Measuring the usage of blood components will help health care providers determine if patients are being infused correctly, or if additional measurements are needed.
• Blood Administration Documentation – Comparing: [Numerator] Number of transfused blood units/doses (bags) with correct documentation for all of the following:
  • Patient identification and transfusion order (or Blood ID Number) confirmed prior to the initiation of transfusion.
  • Date and time of transfusion.
  • Blood pressure, pulse and temperature recorded pre, during and post transfusion.

(Compared To) [Denominator] The total number of transfused red blood cells, platelets, and/or plasma units/doses evaluated. This indicator (metric) will help health care providers measure and ensure that correct documentation and checkpoints are occurring at the bedside.

• Preoperative Blood Type Screening and Antibody Testing – Comparing: [Numerator] Patients with documentation of preoperative type and screen or type and cross-match completed prior to Anesthesia Start Time (Compared to) [Denominator] Elective orthopedic, cardiac & hysterectomy surgeries; patients >18 years of age¹⁴.
  • Implementing this measure can help ensure that the appropriate blood needs for a patient will be available at the time of each elective surgery.
• Preoperative Anemia Screening – Comparing: [Numerator] Patients with documentation of preoperative anemia screening 14 - 45 days before Anesthesia Start Date (Compared To) [Denominator] elective orthopedic & hysterectomy surgeries; patients > 18 years of age¹⁴.
  • It is recommended to check hemoglobin (hgb) levels at least 30 days prior to any elective surgery (when clinically feasible). Early anemia detection can help the surgical team plan an appropriate strategy.

The above listed items are not all inclusive and it is highly recommended that health care providers add additional items as they see fit.

Blood transfusion errors occur in 1 out of every 6,000 procedures, and when they do occur, blood transfusion errors can be serious and life threatening. A 2009 international study found that 70% of all blood transfusion errors can be linked to a failure to perform a final bedside patient check⁹. Oftentimes a nursing professional is the final checkpoint during the blood transfusion process.

Hospitals across the nation have implemented bedside checklists to help reduce the chances of an error at the bedside⁹. One of the key objectives is correct identification of the patient and the matching of the delivered blood to the patient. Several potential issues and tips are:

• Have a process in place for identifying unconscious patients. This is often done with a unique hospital identification number which is assigned to a patient⁶. Any assigned blood request forms and units should have matching identification numbers.
• Understand that different ethnic groups may have different naming conventions. For instance you may have two different patients: Sanchez-Gonzalez and Gonzalez. Errors can occur if the patients are not distinctly identified. If the patient speaks a foreign language, and you are not able to communicate, always check their unique identification numbers with that of any assigned blood⁷.
• Implement a policy of: No identification band, no blood transfusion³.
• Whenever possible the PATIENT should be asked to confirm their identity. Positive identification of the patient before any blood sampling and transfusion of blood and blood products occurs is crucial to patient safety³.
• The nurse responsible for the patient’s care must ensure that the patient has their identification band for their entire hospital stay.
• If for whatever reason an identification band is removed, it is the responsibility of the person who removed band (or the staff member who first notices that missing band) to replace the identification band as soon as possible⁹.
• Unconscious or unknown patients must have a band detailing their unique identification number and gender.
• If a patient is determined to be at an increased risk of a mild reaction, medications such as acetaminophen and/or diphenhydramine (Benadryl), may be useful to have at immediate availability in the patient care area.
• Ensure that the patient has an IV ready before retrieving any blood from the blood bank.
• After the transfusion has begun, the rate of flow should be observed and regulated as per the physician’s instructions⁷.
• Conduct a thorough physical inspection of the patient’s condition prior to a transfusion. Document your findings. This will help to be able to compare and identify any adverse reactions. Conduct a second physical inspection 15 minutes after the transfusion has begun and document your findings¹⁰. Compare.

Despite following each step of an internal process, it is possible for complications to occur during or after a transfusion. The nurse administering the transfusion is often the
first responder. If you suspect a potential complication:

• Stop the transfusion immediately.
• Keep the IV line open. Keep the line open with a normal saline solution.
• Immediately notify the on-call physician and the blood bank representative.
• Monitor the patient’s vital signs.
• Double check the patient’s identification numbers against the blood product’s identification numbers to insure that the correct blood product is being given.
• Intervene as necessary. Record any nurse interventions.
• Start the transfusion again only after obtaining a physician’s order.

As the final step in the blood transfusion process, nurses are at an ideal location to be a final checkpoint in a hospitals blood transfusion process. Positive patient identification and bedside checklists can help nurses drive better patient care in their facilities.

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Reaction Response Guide. http://www.op.nysed.gov/prof/nurse/nurse-transfusionguidelines.htm
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Procedures Performed in Hospitals, 2010. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb149.pdf
12.Quality Net. (2013). Top 8 Hospital Acquired Conditions. http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage
%2FQnetTier4&cid=1228759483171
13.Shander, Aryeh. Gross, Irwin, and Sledge, Sharon. (Updated August 2013). A new Perspective on best transfusion practices. Blood Transfusion. Apr 2013; 11(2): 193–202. doi: 10.2450/2012.0195-12. ; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3626470/
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http://www.jointcommission.org/assets/1/6/pbm_implementation_guide_20110624.pdf
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http://www.who.int/bloodsafety/transfusion_services/Introductory_module.pdf