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Policies Relating to Transfusion of Blood Components and Products

AHS Policies related to blood components and products are listed in AHS Policy PS-59 Transfusion of Blood Components and Products. Additional Calgary Zone-specific policies related to transfusion are listed below.

1. A physician or nurse practitioner's order is required for the transfusion of blood components or plasma protein products and must include either the number of units, volume, or dosage.

2. If any discrepancy or other irregularity is discovered during checks performed prior to transfusion, it must be resolved before proceeding with the transfusion.

3. All labels and tags must remain attached to the unit until discard of the container.

4. Infusion should be completed before expiration of the component/product or within four hours of removal from a temperature-controlled storage unit, whichever is sooner. If a component is required to run over more than four hours, the PCU may request to have it split.

5. Plasma protein (fractionation) products must be administered according to the manufacturer's instructions.

  • Transfusion Medicine will respond to requests for information regarding product dosage and administration by providing the manufacturer's product insert to the requestor.
  • Products issued to physicians' offices or for home administration may be stored in non-controlled refrigerators. It is the responsibility of the physician or user to ensure the product is stored according to the manufacturer's recommendation. In order to acquire more product, the physician office must provide Transfusion Medicine with the product recipient documentation.

6. Blood products may NOT be stored in nursing unit refrigerators, except those specifically designed and controlled for blood storage.

7. Adverse reactions to transfusion and transfusion events (near misses) must be reported to TM as soon as they are recognized.

8. When blood components/products are transferred from a non-CLS site with a patient, they may be transfused at the discretion of the physician attending the patient. It is the responsibility of the transfusing physician/PCU to document the transfusion and advise the sending site of the disposition of the component/product(s). It is preferable for them to be sent to the TM laboratory. Components/products will be accepted into inventory or disposed as per TM policy.

9. Written notification transfusion must be provided by giving the patient the card attached to a Notification of Administration of Blood or Blood Products form and placing the form in the patient's Health Record chart.

10. Units received in a patient care area that will not be transfused must be returned to appropriate storage or to Transfusion Medicine as soon as possible. Units that have been out of controlled storage conditions for more than 60 minutes must be discarded. Advise Transfusion Medicine if units being returned have been out of controlled storage conditions for more than 60 minutes or if units are partially transfused.