| GENERAL RECOMMENDATIONS |
| Education and training are of key importance for safe and effective blood transfusion practice. Education in blood transfusion must be included in the curriculum for all clinical staff involved in prescribing and administering blood. Adequate resource is needed in Trusts to ensure that all staff involved in the transfusion chain in hospitals must receive appropriate training, which must be documented. Effectiveness of training should be assessed with assessment based on competency | National transfusion committee network |
| Mechanisms must be put in place for appropriate and timely communication of information regarding special transfusion requirements | Chief Medical Officer’s National Blood Transfusion Committee (CMO’s NBTC) in England and its counterparts in devolved administrations to make recommendations on suitable mechanisms for implementation by Trust CEOs through Hospital Transfusion Committees, Hospital Transfusion Teams |
| Appropriate use of blood components must be strenuously promoted and evaluated. This must include monitoring for serious adverse effects of alternatives to transfusion | CMO’s NBTC and counterparts to develop action plans |
| Further national initiatives are needed to drive forward blood safety issues in hospital transfusion laboratories | CMO's NBTC in England and its counterparts in Scotland, Wales and Northern Ireland to develop action plans in collaboration with relevant professional bodies |
| Information technology as an aid to transfusion safety should be assessed and developed at National Level. A co-ordinated approach is essential | CMO’S NBTC IT Working group |
| INCORRECT BLOOD COMPONENT TRANSFUSED |
| All newly qualified doctors must receive education in blood transfusion as recommended by the CMO for England. A web-based education package (www.learnbloodtransfusion.org) is included in the FY1curriculum in Scotland and should be implemented throughout the UK | CMO’s NBTC |
| Pending the availability of an effective IT solution, hospitals should take steps to implement robust methods to ensure that the patient’s transfusion history including special requirements is kept up to date and accessible to the transfusion laboratory at all times. A patient held booklet is one possible solution | CMO’s NBTC |
| NEAR MISS |
| Training and education in blood sampling, including the practical aspects of venepuncture and positive patient ID, should be included in the curriculum for medical and nursing students | CMO’s NBTC |
| DELAYED TRANSFUSION REACTIONS |
| Consideration should be given to issuing antibody cards or similar information to all patients with clinically significant red cell antibodies. These should be accompanied by patient information leaflets, explaining the significance of the antibody and impressing that the card should be shown in the event of a hospital admission or being crossmatched for surgery. Laboratories should be informed when patients carrying antibody cards are admitted | The CMO’s NBTC and its counterparts in Scotland, Wales, and Northern Ireland |