4.0 Related Documents 4.1 The following procedures should be read in conjunction with this procedure.

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1 WRH-BT-HP-004 Issue : 005 Effective Date 08/04/2015 Page 1 of Purpose 1.1 The purpose of this document is to safeguard the patient by providing clear instruction to relevant staff on the collection and return (where necessary) of Blood Components and Blood Products between the Blood Transfusion Laboratory and the Clinical area. 2.0 Scope 2.1 All Clinical Nurse and Midwifery Managers. 2.2 All registered Nurses/ Midwives. 2.3 All registered Medical Practitioners. 2.4 Portering/Household Staff. 2.5 Healthcare Assistants rd & 4 th Nursing / Midwifery Students. 3.0 Legislation 3.1 Minimum Requirements for Blood Bank Compliance with Article 14 (Traceability) and Article 15 (Notification of Serious Adverse Reactions and Events) of EU Directive 2002/98/EC. 3.2 ISO 15189:2012 Standard: Medical Laboratories Particular Requirements for Quality and Competence. 3.3 An Bord Altranais (2014) Code of Professional Conduct and Ethics for Registered Nurses & Midwives. 3.4 Medical Council Guide to Professional Conduct and Ethics for Registered Medical Practitioners 7th Edition (2009). 4.0 Related Documents 4.1 The following procedures should be read in conjunction with this procedure. Document Reference HSE S/SE Standard & Transmission based precautions Policy (2011) PPC-IPC-5 Hand Hygiene Policy (2015) PPC-IPC-3

2 WRH-BT-HP-004 Issue : 005 Effective Date 08/04/2015 Page 2 of Responsibilities 5.1 It is the responsibility of the following staff members to adhere to this procedure as outlined in this document. Medical Practitioners. Registered Nurses/Midwives. Portering/Household Staff. Healthcare Assistants. 3 rd & 4 th Nursing / Midwifery Students. 5.2 Clinical Nurse Managers/Midwifery Managers/Healthcare Assistant Manager and the Portering/ Household Service Manager: It is the responsibility of managers to ensure all relevant staff are aware of this procedure have read it, and that it is reflective in their current work practices. It is the responsibility of managers to communicate changes/updates to the procedure to all staff when communicated by the Haemovigilance Clinical Nurse Specialist/ Senior Medical Scientist. The managers have a responsibility to release staff to attend mandatory Haemovigilance training. The managers must maintain their own records of staff who have read this procedure and who have attended Haemovigilance training. 5.3 Registered Nurses/ Midwives: It is the responsibility of all staff to read and comply with this procedure and attend Haemovigilance training when required. It is the responsibility of each professional to practice appropriate transfusion practice safely, competently and effectively, fulfilling his/her professional responsibility within his/her scope of practice (An Bord Altranais 2014). 5.4 Portering/Household Staff, Healthcare Assistants and 3 rd & 4 th Nursing / Midwifery Students: It is the responsibility of all staff to read and comply with this procedure and attend Haemovigilance training when required. 5.5 Medical Practitioners: It is the responsibility of all Medical Practitioners to ensure they are aware of, have read and comply with this procedure. All Medical Practitioners who are required to attend the NCHD Induction Training in UHW must sign the UHW Mandatory Compliance sheet organised by Medical Manpower agreeing to comply with Haemovigilance and Blood Transfusion procedures in UHW. NCHD Induction Training attendance record is maintained by Medical Manpower and a copy sent to the Haemovigilance Department.

3 WRH-BT-HP-004 Issue : 005 Effective Date 08/04/2015 Page 3 of Haemovigilance Clinical Nurse Specialist/Senior Medical Scientist: It is the responsibility of the Haemovigilance Officers to facilitate compliance with Article 14 & 15 of the EU Directive 2002/98/EC. It is the responsibility of the Haemovigilance Officers to provide education & training in Haemovigilance. Note: Non adherence with the standards outlined in this procedure will be investigated by the Haemovigilance CNS/SMS, and will be dealt with via the Blood Transfusion/Haemovigilance Quality System. 6.0 Procedural Sections 7.0 Preparation for Collection of Blood Component or Product 8.0 Location and storage of Blood Components and Blood Products in the Blood Bank Issue Room. 9.0 Collection of Blood Components and Blood Products from the Blood Bank Issue Room Return of Blood Components and Blood Products to the Blood Bank Issue Room Collection and Return of Blood Components and Products from Theatre Fridge. 7.0 Preparation for Collection of Blood Component or Product 7.1 Prior to collection of Blood Components and Blood Products the requesting Nurse/Midwife or Doctor must ensure that the patient has: A correct identity bracelet in situ. A patent intravenous cannula or central access device in situ. Pre transfusion vital signs recorded and documented (Refer to WRH- BT-HP-005) The Blood Component / Product is prescribed, dated and signed by a doctor in the patients Prescription and Administration record for blood and blood components. 7.2 The Blood Component/Products must be transported to the clinical area/ward and the pre-transfusions checks of the blood component/product completed within 30 minutes of removal from the Blood Bank s controlled storage conditions. 7.3 A Blood Collection Form (WRH BT-HF-002, Appendix 1) must be used by all wards when collecting Blood Components / Products from the laboratory with exception of Theatre where printed patient details are acceptable (i.e. addressograph label), if there is not enough time to complete a Blood Collection Form. 7.4 The Blood Collection Form must be completed in the clinical area by a doctor, nurse of midwife and must contain the following: Patients Full Name Date of Birth

4 WRH-BT-HP-004 Issue : 005 Effective Date 08/04/2015 Page 4 of 10 Hospital Number Ward Blood component/product required Person requesting collection (Print/Sign/Date and Time) 7.5 The Blood Collection Form is then taken by the person who is collecting the blood / blood product to the laboratory. 7.6 A designated blood transport box, available for use in each clinical area must be brought to the laboratory for collection of a blood product/ component. If more than one unit is required, the collector must contact the Blood Transfusion Laboratory to pack units in appropriate igloo box. All Blood Products and Components must be transported in the correct blood transport box. Blood Components or Products must not be stored in the blood transport box as this is not temperature controlled. 8.0 Location and Storage of Blood Components and Blood Products in the Blood Bank Issue Room 8.1 All requested Blood Components and Blood Products will be individually labelled with the patients details. 8.2 Product storage locations and collection methods are outlined in Table 1 below. Table 1: Product Storage in Blood Issue Room Product Storage Location Blood Track Kiosk/ Manual Sign Out Log Compatibility Report Form Red Blood Cells Blood Issue Fridge Scan out at Kiosk Designated Pigeon hole Platelets Platelet Incubator Scan out at Kiosk Designated Pigeon hole Anti-D Blood Issue Fridge Sign out on Log Designated Pigeon hole Factor Concentrates Blood Issue Fridge Sign out on Log Designated Pigeon hole Fibrinogen Blood Issue Fridge Sign out on Log Designated Pigeon hole Thawed Plasma Blood Issue Room Worktop Albumin Bottom shelf of Pigeon hole Sign out on Log Sign out on Log With Product With Product

5 WRH-BT-HP-004 Issue : 005 Effective Date 08/04/2015 Page 5 of Emergency Stock: - Four units of Group O Negative Red Cells - Four bottles of 5% Albumin (250mls) These are stored in the bottom right hand side of Issue Fridge - Four bottles of 5% Albumin (250mls) Stored in Theatre Fridge. 8.4 The person who removes any emergency stock must inform the Medical Scientist immediately (2479 or via switch) to allow stocks to be replenished. 9.0 Collection of Blood Components and Blood Products from the Blood Bank Issue Room 9.1 Adherence to infection control standard precautions is required at all times when dealing with blood components and products. Refer to HSE S/SE Standard & Transmission based precautions Policy (2011) and Hand Hygiene Policy (2015). 9.2 On arrival at the laboratory and before entering, the collector must apply an alcohol based hand rub e.g. Spirigel for 15 seconds on clean hands. 9.3 The required compatibility form will be available from the ward collection pigeon holes in the Blood Bank Issue Room. (Note: This may already be in the patient s Prescription and Administration Record if a transfusion episode is current.) 9.4 DO NOT attempt to force the fridge doors open as they are controlled by an electronic lock and ensure that fridge is closed properly after use. 9.5 Collection of Red Blood Cells and Platelets Red Cells and Platelets must be scanned out through the Red Blood Track Kiosk Scan barcoded staff identity badge Select Taking Out, fridge is now unlocked System prompts to remove unit from fridge, using the patients details on the collection form, obtain required unit from appropriate storage location (fridge or platelet incubator) Scan unit barcode number from the front of the unit (Number starting R000 ) into Blood Track Kiosk System displays patient details, check these against the details on the Blood Collection form and the label on the blood product. If correct press YES on screen If any discrepancies are noted do not proceed, select NO. If the wrong unit has been selected return unit to storage and select correct unit If a discrepancy with the patient details is noted contact the Blood

6 WRH-BT-HP-004 Issue : 005 Effective Date 08/04/2015 Page 6 of 10 Transfusion laboratory immediately, do not remove any products for patient If details are correct, select yes Log off from Kiosk Proceed to step Collection of Batch Products Batch Products cannot be scanned out through the blood track system i.e. Albumin, Anti-D, Plasma, and Factor Concentrates However, if the product to be collected is stored in the fridge: scan barcoded staff identity badge to open the fridge Select Taking Out, this unlocks fridge System prompts to remove unit from fridge, using the patients details on the collection form, obtain required batch products from fridge and close the fridge Log off from Kiosk Plasma and Albumin are stored on the bench top/ pigeon hole, therefore the collector is not required to scan barcoded ID at the blood track kiosk for collection of these products Proceed to step Collection of Blood and Blood Products for Emergency Transfusion If Uncrossmatched Emergency O Negative Red cells are required Scan barcoded staff identity badge Select Emergency Blood, this unlocks fridge Remove required units from bottom right hand side of fridge Scan unit barcode number (number starting R000) at the kiosk There will be no patient details to check, a green screen and a prompt of Good will appear. Scan out additional units if required and Log out Notify Laboratory/ Medical Scientist on call as soon as possible that you have removed unit(s) to allow stocks to be replenished and to facilitate storage and transport of red cells in a closed Cell Safe Transport (Igloo) box if more than one unit is required Proceed to step If collecting Emergency Albumin from the bottom drawer of the issue fridge, scan your barcoded staff ID badge at blood track kiosk to unlock issue fridge. Remove requested albumin from the fridge and proceed to step Check patient details on product with the details on the collection form If any discrepancies are noted do not proceed, and contact the Medical Scientist to verify If details are correct, remove first peelable label from the attached compatibility label on the blood product and place in the appropriate column in the Blood Bank Manual Sign Out Log (FORM-PATH-BT-004). Record

7 WRH-BT-HP-004 Issue : 005 Effective Date 08/04/2015 Page 7 of 10 time, date, ward location and legible signature in the appropriate columns Remove the second peelable label from the compatibility label on the blood product and place in the appropriate area on the Blood Collection Form. This collection form is then dated, timed (as per laboratory 24 hour clock), name printed and signed by the collector The Blood Component / Blood Product with the Blood Collection Form and the Compatibility Report form (if available) are transported to the ward / clinical area where it is required in a designated blood transport box On arrival at the ward/clinical area, the person transporting the Blood Component/ Blood Product has a responsibility to hand the component/product to the requesting Nurse/Midwife/ Doctor The recipient of the Blood Component / Product on the ward/clinical area must date, time and sign the Blood Collection Form and place it securely in the Prescription & Administration Record for Blood and Blood Components (WRH-BT-HF-001) Return of Blood Components and Blood Products to Blood Bank Issue Room 10.1 Return of Red Cells or Platelets to the Blood Issue Room Any unit of red cells or platelets that have been removed from the Laboratory and is not for immediate use must be returned to the issue refrigerator or platelet incubator as appropriate in the Blood Bank Issue Room in the designated blood collection box within 30 minutes of its removal Inform Medical Scientist in Blood Transfusion immediately if any component is being returned to the laboratory Scan barcoded staff identity badge Select Putting In, the fridge is now unlocked Scan the barcode from the front of the unit (Number starting R000 ) If unit is returned within the appropriate timeframe (30mins) a Green Good Screen will appear, place unit in appropriate storage location If blood is not returned within appropriate timeframe (30mins) a Red Stop screen will appear. Do not place unit back into fridge and contact transfusion laboratory/on-call Medical Scientist immediately Return of All Other Blood Components and Blood Products to the Blood Bank Issue Room If the Component/ Product is not required for immediate use it must be returned to the Blood Transfusion Department The Blood Component / Blood Product must be given to the Medical Scientist in the Transfusion Department and sign the component/product back into the Blood Bank Manual Sign Out Log (FORM-PATH-BT-004) in the appropriate section.

8 WRH-BT-HP-004 Issue : 005 Effective Date 08/04/2015 Page 8 of Collection and Return of Blood Components and Blood Products from Theatre Fridge 11.1 Collection and Return of Blood Components and Blood Products from the Theatre Fridge is performed as outlined in this procedure for the Blood Issue Room If blood is to be stored in theatre fridge for theatre use, scan ID badge to unlock fridge Scan red cells through Blood Track and place units and compatibility form in Theatre fridge Sign batch products into theatre fridge using theatre sign in log and similarly store the batch product along with the compatibility form in the fridge Platelet must NOT be scanned into the Theatre Fridge, they must be brought directly to theatre Retention and Storage of Blood Transfusion Records 12.1 The EU Blood Directive mandates for the retention of all relevant documentation relating to the traceability of Blood component/products for at least 30 year. This will include information relating to the Collection of Blood Components/Products from the Blood Bank Issue Room Implementation Plan 13.1 This document is available on Q pulse and in the Haemovigilance section of the Laboratory Users Manual which is accessible via the Lab Web Enquiry Icon on the desk top in all clinical areas and The Haemovigilance Clinical Nurse Specialist/ Senior Medical Scientist will distribute this document via Q pulse/ to Consultants/Clinical Nurse/ Midwife Managers, the Healthcare Assistant Manager and the Portering/ Household Service Manager Consultants/Clinical Nurse/ Midwife Managers, the Healthcare Assistant Manager and the Portering/ Household Service Manager must bring this procedure to the attention of staff in their Department/ Clinical team and to maintain an updated list of same Evaluation and Audit 14.1 The content and structure of this policy will be evaluated and updated in two years from the date of issue. The content of this procedure will be audited by Haemovigilance as per Audit Schedule. Any changes to this procedure will be communicated via and Q pulse.

9 WRH-BT-HP-004 Issue : 005 Effective Date 08/04/2015 Page 9 of Bibliography 15.1 BCSH Guideline (2009) Guideline on the Administration of Blood Components Hand Hygiene Policy (2015) UHW/STGH/KROH/WGH/SLGH & Integrated Services Area CW/KK/Sth Tipp./Waterford & Wexford. Q pulse: PPC-IPC Health Service Executive South/South East Network Transmission Based Precautions. (2011) Q pulse: PPC-IPC Laboratory Retention and Storage of Pathological Records Procedure (2012) Q pulse: WRH-PATH-LP National Blood Users Group (2004). Guidelines for the Administration of Blood and Blood Components. Dublin: National Blood Users Group 15.6 Prescribing and Administration of Blood Components and Products in University Hospital Waterford (2015) Q pulse: WRH-BT-HP Appendices Appendix 1: Blood/Blood Components Collection Form (WRH-BT-HF-002)

10 WRH-BT-HP-004 Issue : 005 Effective Date 08/04/2015 Page 10 of 10 Appendix 1: Blood/Blood Components Collection Form