Reporting & Documentation

Overview

Documenting and reporting complications of blood transfusion involve many aspects and interrelationships. Policies and procedures will vary from site to site. Where applicable, please find examples of the types of reporting that are required.

Responsibilities of Medical and Nursing Staff

Physicians and nurses attending to patients who experience suspected transfusion complications should perform the following documentation and reporting functions:

• Report suspected reactions immediately to the attending physician and transfusion service.
• Document the patient's signs and symptoms and implicated donor units and send them to the transfusion service, as shown in this example from the National TTI Surveillance System (TTISS):
  - Canadian Transfusion Adverse Event Reporting Form

Note: Canadian Blood Services offers no endorsement of and assumes no liability for the currency, accuracy, or availability of any information on these sites.

• Maintain records of the complication in the patient’s medical record, including the report of the investigation completed by the transfusion service.

Note: Documentation must be maintained for all transfusions, whether or not complications occur.

Responsibilities of the Transfusion Service

The transfusion service is responsible for several aspects of documenting and reporting transfusion reactions and complications. These include documenting and reporting:

• results of transfusion reaction investigations to the attending physician;
• accidents and errors to the hospital transfusion committee;
• significant complications to the manufacturer and/or distributor;
• significant complications to other authorities as specified by provincial or federal regulations.

The types of reactions that should be reported are provided in the Standards for Blood Safety and below (under Canadian Blood Services).

Responsibilities of Canadian Blood Services

Canadian Blood Services, the blood supplier in all Canadian provinces and territories except Quebec, receives reports of serious adverse reactions from transfusion services and reports them to Health Canada.

IMPORTANT: In Canadian Blood Services’ Circular of Information, review a detailed description about the reporting responsibilities and relationships between itself and transfusion services, including transfusion-transmissible diseases: Section A6. Reporting Serious Adverse Reactions.