Page1/2 DOCTOR TO COMPLETE THIS FORM WHEN MNCMS IS DOWN Refer to Management & Investigation of Adverse Transfusion Reactions PP-CS-HV-2 Available in Q Pulse __________________________________________________________________________________________ Patient’s First Name_______________Surname___________DOB__________Hospital Number___________ Gender Female/ Male_______ Ward/clinical area __________ Patient Diagnosis___________________ Component/Product transfused Pleast tick appropriate box and complete all sections Red cells Pre transfusion Hb________ Plasma Platelets Pre Transfusion Platelet count____________ Other product specify_____________ Volume transfused at time of reaction __________________ Volume in Bag_________________________ Donor number/Batch number _________________________ Special requirements_________________ Date & Time transfusion started _______________________ Time of reaction______________________ Blood Warmer used? Yes No Was prophylactic medication administered? No if Yes specify_________________________________ Was anything injected into the pack or giving set? No if Yes specify___________________________ Was a blood administration set used? Yes No Reason for transfusion ________________________________Any previous transfusions Yes No Any previous reactions No Yes If yes specify_________________________________________________ Any pregnancies No Yes if yes specify parity__________________ Pre transfusion observations: Observations at onset of reaction
Temp: ______ Pulse: ________B/P: _______Respirations: ________ Temp: ______ Pulse: ________B/P: _______ Respirations: ________
Clinical signs and symptoms tick BOX as appropriate Apprehension/feeling of doom Raised Temp ≥2o above baseline Chills Rigor Increased pulse rate Backache Pain at infusion site Chest pain Nausea/Vomiting Hypotension Hypertension Breathlessness/dyspnoea Itching Urticaria Anaphylaxis Lip/Tongue Swelling Jaundice Decreased urinary output Dark or red urine Diffuse bleeding/petechiae Other specify_____________________________________________________ Type of reaction suspected ___________________________________________________________________ If the reaction has implications for the safety of associated blood components (eg Transfusion Transmitted Bacterial infection, Viral infection, Parasitical infection, Transfusion Related Acute Lung Injury) YOU must inform the medical scientist on duty immediately so that a RAPID ALERT can be instigated. Name of medical scientist contacted________________________ Date/Time contacted__________________
Reaction reported by Dr_____________________MCRN :________Date______ Time______Bleep No_______ PLEASE MAKE A COPY OF COMPLETED PAGE 1 AND 2 BEFORE DISPATCH TO LABORATORY AND SCAN TO PATIENT ELECTRONIC CHART IN REACTION ENCOUNTER WHEN BACK ON LINE
RF-CS-HV-1 Ver. 2