Appendix 2
Appendix 2Chart Audit/Transfusion Reaction InvestigationLocation: MRN: Name:Date of transfusion: Time:Previous Transfusions: Yes No When: Consent: YesNo Transfusion Record: Where located?Order on chart/CPOE: Number of units: Time specified/Infusion rate:Blood component/ Product Type: unit number:___________________ Amount transfused: Patient wearing ID: Legible:IV establishedTransfusion record stamped on both sides: Signed by two HCP:Time started:Pre-Transfusion vital signs checked within 30 minutes prior to transfusion: Yes No If not, specify Actual time: __________Were vital signs checked 15 minutes after start of transfusion?Multiple units given?Symptoms: Start time Time Tx Rx resolved________________________FeverFlushingNausea VomitingChills/rigorsDyspnea/SOBAnaphylaxisUrticaria (hives)WheezingDiffuse HemorrhageRashHypotensionJaundiceItchingHypertensionPainTreatment: AntipyreticDiureticsO2 supplementAntihistamineAnalgesicsEpinephrineICU transferSteroidIntubation/VentilationFluidAntibioticsComments /Notes:Clinical Investigation Worksheet (For Transfusion Safety Nurse Only) Last Name: _______________________ First Name: ___________________ M / FTransfusion Date:Transfusion Time:Current Pt. Location:History:Meds:More than one blood component or blood product transfused? Yes / No Volume:__________Unit Tx’dVital SignsTimeTempBPHRRRO2 SatFIO2CommentPre-Tx15 minEndComments:Tests ordered (chart)CBCBlood CulturesTest resultsHaptaglobinGroup and ScreenBili, LDH,UrinalysisHgbBiliDATaPTT, INR, fibrinogenPlasma HbLDHChest X-rayBlood GasesLytes, CreatReticFluid Balance Transfusion Reaction reviewed by TM Technical Specialist / Operations Leader Transfusion Reaction reviewed by Transfusion Safety Nurse Transfusion Reaction reviewed by TM Medical Director Transfusion Reaction reported in SoarianIf applicable:Canada Vigilance form faxed to: Health Canada ManufacturerMD CONCLUSION: Acute Hemolytic Transfusion ReactionAnaphylactic ShockAseptic MeningitisBacterial ContaminationDelayed Hemolytic Transfusion Reaction Delayed Serologic Transfusion ReactionFebrile-Non-Hemolytic Transfusion ReactionHypotensive ReactionIVIG Major Allergic ReactionMinor Allergic ReactionNo Incompatibility DetectedNOT Transfusion RelatedOther ___________________Post-Transfusion PurpuraThrombosisTransfusion-Associate Graft-Versus-Host Disease Transfusion-Associated Circulatory Overload (TACO)Transfusion-Associated DyspneaTransfusion-Related Acute Lung Injury (TRALI)Transfusion-Transmitted InfectionImputability: Definite Probable Possible Doubtful Ruled Out Grade: 1 2 3 4For Future Transfusion:FOR TM: Store with other TRANSFUSION REACTION documentation and copy of final report with conclusion ................
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