Surname
BLOOD PRODUCT CONSENT, PRESCRIPTION AND ADMINISTRATION FORM
Surname
BLOOD PRODUCT CONSENT, PRESCRIPTION AND ADMINISTRATION FORM
TRANSFUSION HISTORY
Has the patient previously received blood products? Yes No Unknown
If yes, has the patient had a previous reaction? Yes No Unknown
Details: _________________________________________________________
Premedication required? Yes No
If yes, prescribe on medication chart
EXISTING VALID CONSENT OR UNABLE TO OBTAIN
This patient provided consent for blood products on _____ /_____ /_____ on the Consent to Procedure form.
This patient provided consent for blood products for a 12 month period on _____ /_____ /_____.
This patient could not give consent for blood products because the treatment was a clinical emergency and the patient / substitute decision maker was unable to sign the consent form. There was no indication that the patient would have objected to receiving blood products (consent should be sought retrospectively).
CONSENT FOR BLOOD PRODUCT
Duration of consent: This hospital admission.
12 months (Recurrent transfusion / infusion / injection. Consent is valid for 1 year from date of consent unless clinical condition changes or is withdrawn).
Blood Product:
Blood components (red cells, platelets, fresh frozen plasma (FFP), cryodepleted plasma and/or cryoprecipitate)
Factor concentrates Albumin
Immunoglobulins
Clinical condition / indication for administration of blood product/s:
Declaration of doctor obtaining consent:
have explained the following information to the patient or substitute decision maker
• the reason for the proposed administration of the blood product/s
• the proposed blood product to be administered
• the risks and benefits of the blood product, and the risks or consequences of not receiving the product
• the availability and appropriateness of any other blood management strategies
The patient has been given the opportunity to ask questions and I have provided suitable written information when appropriate.
Full name (printed)
Designation
Signature Date _____ /_____ /_____
Patients declaration:
1. I understand that administration of the blood product/s may be a necessary part of my medical treatment.
2. I acknowledge that the doctor has discussed the benefits and risks of the blood product/s, as well as appropriate alternative treatments.
3. The doctor has discussed the possible consequences of refusing this treatment.
4. I acknowledge that I have had the opportunity to ask questions and request further information.
I consent to blood products OR I do not consent to blood products (please complete Refusal of Consent to Blood Product
Transfusion form)
Patient’s full name (printed)
Signature
Substitute decision maker
Date _____ /_____ /_____
Specific language requirements: I have interpreted the dialogue between the patient and the health practitioner to the best of my ability, and have advised the health practitioner of any concerns.
Interpreter’s full name (printed)
NAATI number
Signature Date
U.R. Number
Surname
Given
BLOOD PRODUCT CONSENT, PRESCRIPTION AND ADMINISTRATION FORM
Order and Preparation
TRANSFUSION CHECKLIST
Initial as you check per transfusion or mark N/A
Action 1 2 3 4 5 6 7 8
1 Plan of care has been discussed with the patient
2 Valid, informed consent has been obtained
3 Appropriate written information provided to patient, if required
4 Transfusion history complete and considered every transfusion episode
5 Blood prescription complete, including any special requirements
6 The indication for transfusion / infusion / injection has been documented
7 Patient assessed, including baseline observations (T, P, RR, BP & SaO2) and pre-existing rashes within 60 minutes before commencement. Call bell within reach
8 IV access is patent and appropriate
9 Administer premedication, if required, within an appropriate time
10 Prepare equipment. Blood components must be transfused using a blood administration set incorporating 170-200 micron filter
Collection and Transport Note: Steps 1-10 must be completed before proceeding Initial as you check per transfusion or mark N/A Action 1 2 3 4 5 6 7 8
11 Blood Product Pick-up / Collection form complete
Record date and time (24-hour clock)
12 Blood product removed from temperature controlled storage (Time recorded on register / provided by Pathology Provider) / /
Administration and Documentation Note: Steps 13-16 & 18 require a Double Independent Check at the patient’s side immediately before transfusion. Each Caregiver (1 must be an RN/RM or Medical Officer) must independently view each item / element and confirm all details are correct Initial as you check per transfusion or mark N/A
13 Patient (if conscious and competent) stated and spelt their full name and date of birth (DOB) and the details were identical to the patient’s identification (ID) band
14 The patient’s ID (family name, given name, DOB and URN) are identical to those on the patient compatibility label attached to the blood product and blood product prescription. If URN is missing or from another facility patient address or sex may be used.
Blood product check. Not all elements are relevant for vials / bottles
• Blood product type same on prescription, patient compatibility label attached to blood product (and patient compatibility report where used) and pack (or bottle / vial)
• Special requirements met e.g. irradiated, CMV negative
15
• Donation number and blood group on the patient compatibility label identical to the blood pack
• The blood group on the pack is compatible with the patient
• Product within expiry
• Product integrity confirmed e.g. no leaks, evidence of discolouration, clots etc.
16 Correct infusion rate (start each pack slowly where possible - half the prescribed hourly rate for the first 15 min)
17 Monitor – Close visual observation for the first 15 minutes and frequently for the remainder of the transfusion. As a minimum, T, P, RR, BP & SaO2 15 minutes after starting each pack, hourly and on completion.
18 Infusion rate increased to maximum as per prescription (if pack started slowly), provided no signs & symptoms of an adverse reaction
19 Documentation complete, including the transfusion finish time
IDENTIFICATION AND MANAGEMENT OF TRANSFUSION RELATED ADVERSE EVENTS
If you suspect a transfusion reaction:
transfusion and activate emergency procedures if required Check vital signs
Surname
Given
BLOOD PRODUCT CONSENT, PRESCRIPTION AND ADMINISTRATION FORM
THE DECISION TO TRANSFUSE
The decision to transfuse, and the consideration of other blood management strategies, must be based on a thorough clinical assessment of the patient and of that person’s individual needs. For Patient Blood Management Guidelines, visit https://www.blood.gov.au/pbm-guidelines IN HAEMODYNAMICALLY STABLE PATIENTS NOT ACTIVELY BLEEDING
RBC is often appropriate RBC may be appropriate RBC is often unnecessary Single unit red cell transfusion should be the standard for non-bleeding patients. Reassess your patient before ordering any additional units.
Weight (kg):__________________________________
*Clinical code: Reason for administration of blood product MUST be completed by prescriber
BLOOD PRESCRIPTION (1 blood product / unit per line only)