Oxford University Hospitals
Version 4.0 - June 2012
73. Blood arriving at the NOC may be stored in the blood fridge providing it is scanned into
the fridge using the BloodTrack system, and that it has not been out of temperature
control for longer than the designated time.
74. If more blood is required for the patient, please contact the Blood Transfusion Laboratory
and send a sample for grouping and crossmatching. (Patients being transferred from the
NOC will not usually require a new sample, please check with the laboratory.)
75. Units which arrive in the Trust which have been incorrectly stored or transported without
a validated cool box must be marked as unsuitable for transfusion and returned to the
Blood Transfusion Laboratory for disposal.
8. Identifying the patient immediately prior to commencing
transfusion (bedside check)
76. Any staff undertaking this procedure must be competent in the administration of
intravenous drugs, have been trained in safe transfusion practice and have passed the
required eLearning modules in accordance with the mandatory training and competence
framework for blood transfusion (appendix 1).
77. BloodTrack Tx must be used for checking every blood component immediately prior to
the transfusion (‘begin transfusion or ‘emergency transfusion’ function) as it supports and
promotes the correct procedure, which includes key visual and verbal checks of patient
identification and the scanning of bar codes to ensure an exact match between blood
compatibility label and patient.
78. Transfusions must not take place without a wristband attached and verified as correct for
the patient which matches identically with the patient identification on the blood
compatibility label.
79. The ‘begin transfusion’ (bedside) check must always be performed at the patient’s side
immediately prior to commencement of the transfusion. Once the check has been
successfully completed, the blood component should be used to prime the blood giving
set (if necessary) at the bedside and the transfusion commenced without delay. If the
blood component leaves the patient’s side after the bedside check, or if another member
of staff performed the check but did not commence the transfusion, a repeat ‘begin
transfusion’ (bedside) check will be required immediately prior to commencement of the
transfusion.
80. One member of staff, identified by scanning his/her ID badge bar code, is accountable for
carrying out an identity check of the patient and the blood component at the patient’s
bedside. The person must be a healthcare practitioner who is currently registered with
the Nursing and Midwifery Council (NMC) the General Medical Council (GMC) or the
Health Professions Council (HPC).
81. Any discrepancy in the identity checks of the patient and the blood component must be
reported to the Blood Transfusion laboratory immediately and the blood must not be
transfused until the discrepancy has been resolved, either by re-taking a blood sample for
crossmatching or by sending the blood back to the Blood Transfusion Laboratory to
correct a mistake, depending on the cause of the mismatch. The incident must be
reported in line with the Incident Reporting and Investigation Policy.
81.1. If the need for blood transfusion is very urgent (blood needed within 5 minutes)
and no more crossmatched blood is available, use of emergency stocks may be
considered in preference to the mislabelled blood.