More than 4.5 million people require blood transfusions annually, many of which are life-saving.¹ But if blood types are mismatched, transfusions can be deadly.¹ The cost in human suffering is great. And soon, hospitals in which an error occurs will face financial consequences, as well.

Starting Oct. 1, the Centers for Medicare & Medicaid Services will no longer reimburse hospitals for treating several hospital-acquired complications that are reasonably preventable with the aid of evidence-based guidelines. Among the complications are blood incompatibility events.² For example, if a patient experiences a hemolytic transfusion reaction due to a blood incompatibility error, the hospital will not receive reimbursement for the care related to the transfusion reaction.¹

The Joint Commission (TJC) also reviews hemolytic transfusion reactions involving major blood group incompatibilities, under its sentinel event policy. The policy encourages hospitals to report unexpected events that cause death or serious injury. After reporting the event to TJC, the hospital must perform a root cause analysis and develop a plan to ensure the event does not recur.³ After TJC incorporated major blood group incompatibilities into its sentinel event policy, hospitals reported 12 cases over a three-year period. After reviewing the cases, TJC issued a sentinel event alert for healthcare agencies in 1999. Of the 12 reported cases, 10 resulted in death. All but one of the cases involved failure to follow policies for identifying a patient and the correct blood product for that patient.⁴

Three factors that commonly lead to ABO incompatibility errors have been identified: mislabeling of the blood specimen for crossmatching, misinterpretation by the blood bank, and misidentification of the patient before blood transfusion.⁵ Errors are often fatal; death can occur when as little as 30 mL of incompatible blood is transfused.⁶ But all blood incompatibility errors are preventable. With strict adherence to established policies, blood incompatibility errors can be eliminated. Nurses, who generally administer blood products, must follow facility policy to ensure that they give the right blood product to the right patient.

There are four blood types: A, B, AB, and O. They are named according to the presence of two antigens (substances that make the immune system respond): A and B. Type A blood has only the A antigen, Type B has only the B antigen, Type AB has both A and B antigens, and Type O has neither A or B antigens. Blood types are further classified as Rh-positive or Rh-negative. Blood is Rh-positive when the blood antigen D is present and Rh-negative when antigen D is absent.

Health workers must know the blood type and Rh classification of the recipient patient and the donor to ensure blood compatibility. A patient with Type A blood can receive types A and O blood. Patients with Type B blood can receive types B and O. Those with type AB blood can receive types A, B, AB, and O. Patients with Type AB blood are called “universal recipients” because they can receive any blood type. Patients with Type O blood can receive only Type O blood. However, almost anyone can receive Type O blood, so those with Type O blood are called “universal donors.” Type O blood is commonly administered in emergencies, such as severe trauma, when no time is available to test blood for compatibility. Patients with Rh-positive blood can receive Rh-positive or Rh-negative blood, but a patient with Rh-negative blood can receive only Rh-negative blood.

Blood can be administered as whole blood or one of its components. Most patients do not need all the components in whole blood; they receive only the component essential to treat their illness, such as red blood cells, platelets, fresh frozen plasma, or cryoprecipitate (the portion of blood plasma that contains clotting factors).

Popular RBCs

RBCs are the most often transfused component,  prepared by removing the plasma from whole blood. Each unit of RBCs contains about 42 to 80 grams of hemoglobin or 128 to 240 mL of pure RBCs, depending on the hemoglobin level of the donor, volume of the original whole blood collection, and collection method. RBCs should be ABO and Rh identical to the patient for transfusion.

RBCs are indicated for the symptomatic relief of oxygen-carrying capacity deficiency or tissue hypoxia caused by inadequate circulating red cell mass. RBCs are rarely indicated when the patient’s hemoglobin is above 10 g/dL. But they may be indicated when the patient’s hemoglobin is 6 g/dL to 10 g/dL in the presence of organ ischemia. RBCs are also indicated for exchange transfusion in patients with disorders such as hemolytic disease of the newborn or acute chest syndrome associated with sickle cell disease.⁷ RBCs are not indicated for treatment of anemia that can be treated with other therapies, such as iron or erythropoietin stimulating agents, such as epoetin alfa (Epogen). Moreover, they should not be administered as a source of blood volume or oncotic pressure (pressure exerted in the circulatory system by proteins in blood plasma) or to improve wound healing.⁷

Platelets can be obtained by removing them from a unit of whole blood or through apheresis. During apheresis, blood is drawn from a donor into an apheresis apparatus that separates the blood components, retains the platelets, and returns the remainder of the blood back to the donor. Platelets obtained with apheresis contain about six times as many platelets as a unit of platelets obtained from whole blood.⁸ When platelets are obtained from whole blood, platelets from four to 10 random donors are pooled for one adult dose. Platelets should be ABO-identical to the patient, and Rh-negative patients should receive Rh-negative platelets when possible.

Platelets are indicated for treating bleeding caused by a critically low platelet count or functionally abnormal platelets. They may also be administered to prevent bleeding in patients with low platelet counts who must undergo an invasive procedure or who are actively bleeding. Platelets should not be given to patients with autoimmune thrombocytopenia (platelet abnormality or deficiency caused by a malfunction of the body’s immune system) or thrombocytopenic purpura (a systemic illness characterized by areas of ecchymosis and low platelet count) unless they are experiencing life-threatening hemorrhage.

Fresh frozen

Fresh frozen plasma is derived from the noncellular component of blood that is separated and frozen after donation. Similar to platelets, plasma can be separated from whole blood or obtained by apheresis. After plasma is obtained, it is frozen within six hours and stored at temperatures below 18 C. When fresh frozen plasma is needed for transfusion, it is thawed in water and infused immediately. If it cannot be transfused immediately after thawing, it can be stored at 1 C to 6 C for up to 24 hours. Fresh frozen plasma contains clotting factors such as Factor VIII, VIII:vWF (von Willebrand’s factor), fibrinogen, fibronectin, and Factor XIII. Fresh frozen plasma should be ABO identical to the patient.

Fresh frozen plasma is indicated for patients with a history of clotting factor deficiency who are actively bleeding or at risk for bleeding. Fresh frozen plasma is also indicated for thrombotic thrombocytopenic purpura and coagulopathic bleeding associated massive transfusion. It may also be administered to reverse bleeding associated with warfarin (Coumadin) therapy or to emergently reverse the effects of warfarin. The effects of warfarin are commonly reversed with fresh frozen plasma in patients who suffer head trauma or intracerebral hemorrhage or in patients who need emergency surgery. Fresh frozen plasma is typically administered until the patient’s international normalized ratio is less than 1.4.⁹

Fresh frozen plasma should not be given to correct coagulopathy that could be successfully treated with vitamin K or to increase blood volume or albumin concentration. Moreover, it should not be given to normalize coagulation studies when the patient shows no signs of bleeding.

In contrast to other blood products, cryoprecipitate is prepared from another blood product and not directly from whole blood. Cryoprecipitate is derived by thawing a unit of fresh frozen plasma at temperatures from 1 C to 6 C and then recovering the cold precipitate. Within one hour of recovery, the precipitate is refrozen. When needed for transfusion, cryoprecipitate is placed in a protective plastic wrap and thawed in a waterbath. It should be transfused as soon as possible after thawing or within four to six hours. Cryoprecipitate contains concentrated levels of clotting factors, such as Factor VIII:C, von Willebrand’s factor, Factor XIII, fibrinogen, and fibronectin. Compatibility testing is not necessary with cryoprecipitate; however, an ABO-compatible product is preferred.⁷

Cryoprecipitate is indicated for bleeding that occurs with deficiencies in fibrinogen and Factor XIII. Cryoprecipitate should be administered only when lab tests substantiate a deficiency in a particular clotting factor. Patients with hemophilia A or von Willebrand’s disease should not receive cryoprecipitate unless concentrates containing Factor VIII:C or von Willebrand’s factor are not available.⁷

A perfect match

After a transfusion is ordered, properly obtain and identify a blood specimen for typing and crossmatching. Before obtaining the specimen, identify the patient using two patient identifiers, which can include the patient’s name, assigned ID number, or telephone number or other person-specific identifier. Bar coding including two or more specific patient identifiers may also be used. The patient should be involved in the identification process if possible.¹⁰ Obtain the specimen per facility policy, label it at the bedside in the patient’s presence, and send it to the lab immediately.

Assess the patient carefully to determine whether a transfusion is indicated. Check the patient’s past medical history for prior transfusions and reactions. If the patient experienced a transfusion reaction in the past, specially prepared blood products or premedication with acetaminophen (Tylenol) and diphenhydramine (Benadryl) may be necessary. Assess the IV catheter for patency and check that it is an adequate size for transfusion. An 18-gauge catheter is best, but 20-gauge is sufficient to prevent hemolysis.¹¹

Next, verify that informed consent has been obtained. Check the provider’s order noting the indication, the type of blood product to be infused, the infusion rate, and any premedication. Gather blood administration supplies including an IV pole, blood administration set, normal saline IV solution, thermometer, sphygmomanometer, blood pressure cuff, stethoscope, and gloves. Normal saline IV solution is the only IV solution compatible with blood. Other IV solutions cause blood cell hemolysis.

Obtain and document baseline vital signs before obtaining the blood product from the blood bank. Notify the provider of vital sign abnormalities. Vital sign abnormalities may require follow-up treatment before the administration of the blood product, or the provider may opt to withhold the transfusion until the patient’s condition stabilizes. Compare vital signs during the transfusion with baseline vital signs; deviation from baseline during transfusion may signal a transfusion reaction.

No slip-ups

Obtain the blood product from the blood bank according to your facility’s policy. Blood banks usually require staff to bring a properly labeled pick-up slip with them to pick up the blood product. The slip confirms the indication and the blood product and amount to be transfused. It also verifies that a functioning IV catheter is present and the patient has signed an informed consent. Blood must be transfused within four hours of leaving the blood bank refrigerator — having the catheter and consent ready helps reduce delays that might unnecessarily waste blood. Check the expiration date and carefully inspect the blood product for discoloration, cloudiness, excessive air, or clots. Return any questionable blood product to the blood bank.

Before starting the transfusion, begin a two-person verification process in the presence of the patient. Match the blood product with the provider’s order and then match the blood product to the patient with the help of a second qualified healthcare worker. Use an automated identification system, such as bar coding, if available. When a two-person identification process is used, one of the healthcare workers must be the qualified tranfusionist who is going to administer the transfusion, and the second healthcare worker must be qualified to participate in the identification process.¹² Both healthcare workers involved in identification should sign, date, and time the blood bank slip attached to the blood product. Make sure that the blood bank slip remains attached to the blood product container until the transfusion is complete so the product can be identified in case of a transfusion reaction.

Perform hand hygiene and put on gloves. Remove the blood administration set from the package and label the tubing with the date and time. Close the clamps on the administration set. Place one of the spikes from the “Y” administration set into the port of the normal saline solution container. Hang the normal saline solution container on an IV pole. Prime the set with normal saline solution, filling the filter completely. Close the clamp on the normal saline side. Spike the blood product bag with the unused side of the “Y” administration set. Hang the blood product container on the IV pole and then slowly open the clamp closest to the blood product. Attach the distal end of the administration set to the IV catheter using aseptic technique. Adjust the flow rate as prescribed, using the roller clamp. Remove the gloves and perform hand hygiene.

Remain with the patient during the first five minutes of the transfusion and obtain vital signs. Keep in mind that most severe transfusion reactions occur within the first few minutes of transfusion and can occur when as little as 30 mL infuses. Make sure the patient’s call bell is within reach and instruct the patient to call immediately with symptoms of a transfusion reaction, such as back pain, restlessness, nausea, tachycardia, hypotension, fever, chills, shortness of breath, or itching.

Obtain and document vital signs in 15 minutes, again in 30 minutes, and then hourly through the remainder of the transfusion or more often if indicated. Obtain and document a final set of vital signs at the completion of each unit of blood product. Assess heart and breath sounds.

When the transfusion is complete, close the clamp closest to the blood product, turn on the normal saline solution, and clear the blood tubing. Perform hand hygiene, put on gloves, and disconnect the administration set from the IV catheter. Maintain the IV catheter according to facility policy. Remove the blood slip from the blood product container and attach it to the patient’s medical record. Discard the container and administration set in the receptacle specified by facility policy. Remove gloves and perform hand hygiene. After the transfusion, record the patient’s response to the transfusion in the patient’s medical record. Document the volume of blood product infused on the intake and output record.

Reacting to a reaction

If a transfusion reaction occurs during blood administration, stop the transfusion immediately. Do not flush the remaining blood in the tubing into the IV catheter. Perform hand hygiene, put on gloves, and disconnect the administration set from the IV catheter. Maintain the IV catheter according to your facility’s policy. Obtain the patient’s vital signs, assess heart and breath sounds, and administer treatment as prescribed. Keep in mind that severe transfusion reactions can quickly progress to shock and even death. Early recognition and treatment are the key to improving patient outcomes.

Several types of transfusion reactions of varying severity exist. The most severe is an acute hemolytic reaction, which occurs as a result of an incompatibility error. The patient’s immune system destroys the transfused RBCs because the antigen on the transfused cells is incompatible with the antibody in the patient’s circulation. An acute hemolytic reaction typically begins with an increase in temperature and heart rate. Other signs and symptoms include chills, dyspnea, chest or back pain, abnormal bleeding, or shock. Blood pressure instability is common depending upon the magnitude of compensatory mechanisms and the phase of the antigen-antibody event.⁷ If an acute hemolytic reaction occurs, the remaining blood product is returned to the blood bank for analysis, and a blood specimen is drawn from the patient and sent to the lab for tests. Treatment focuses on stabilizing BP, correcting coagulopathy, and maintaining urine output.

A delayed hemolytic reaction occurs when a patient’s body slowly attacks antigens, other than the ABO antigens, located on the transfused blood cells, causing blood cell destruction. The transfused cells break down days or weeks after transfusion, causing a drop in RBC count. The patient usually remains asymptomatic. In rare cases, renal failure may develop. Patients with a delayed hemolytic reaction typically have had several transfusions in the past. They must undergo special screening before they can receive additional transfusions.^13,14

An allergic reaction is the most common type of transfusion reaction, occurring when the body reacts to plasma proteins in the blood product. Symptoms include hives and itching, easily treated with diphenhydramine.^13,14

A febrile reaction occurs when the body reacts to white blood cells in transfused blood. Patients develop a sudden fever during the transfusion or within 24 hours after the transfusion. Chills, headache, nausea, and malaise may accompany the fever. Acetaminophen is usually given for symptoms. Patients who have had several transfusions and women who have had several pregnancies are at risk for febrile reactions. At-risk patients should receive leukoreduced blood products, in which white blood cells are filtered out during preparation.^13,14

Transfusion-related lung injury usually occurs within one or two hours of transfusion but can occur up to six hours later. It typically occurs with transfusions of platelets and fresh frozen plasma, but can occur with RBCs. The cause is unknown. Acute shortness of breath and sometimes high fever develop. The patient usually needs supplemental oxygen, but sometimes endotracheal intubation and mechanical ventilation are necessary. Transfusion-related lung injury can be fatal, especially in patients who were critically ill before the transfusion.^13,14

Graft-vs.-host disease occurs in patients who have a severely weakened immune system. The weakened immune system doesn’t recognize the foreign white blood cells in the transfused blood and allows them to attack the patient’s tissues. About a month later, the patient develops a fever, rash, diarrhea, and hepatic dysfunction. Graft-vs.-host disease can be prevented in high-risk patients by treating RBCs with radiation before transfusion. This stops the donor white blood cells from functioning.^13,14

Since testing began, the U.S. blood supply has become extremely safe, but no testing is fail-safe. Although a rare occurrence, blood transfusions can transmit infections caused by bacteria, parasites, and viruses. Bacteria on a donor’s skin can contaminate blood. Platelets are at highest risk because they are stored at room temperature and bacteria thrive at room temperature. Patients receiving contaminated blood may show signs of bacteremia within hours of transfusion.^13,14 Hepatitis B and C and HIV can also be transmitted through blood products. But donors are questioned about risk factors linked with hepatitis and HIV, and blood is screened for the viruses. Blood is also screened for syphilis, West Nile virus, and HTLV-I and HTLV-II, viruses linked to T-cell leukemia and lymphoma.^13,14

Blood incompatibility errors can be deadly, but with strict adherence to policies, all are preventable. The steps described above will prevent errors and save lives.