JPAC Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee

Traceability in Emergency Situations

Issued June 2007

Traceability Issue: Transfer of blood with a patient to a different hospital under emergency situations

The following question was raised with the MHRA.

Q. "What do I document when blood components are received with a patient from another Hospital under emergency situations (e.g. emergency surgical procedures) and transfused without notifying the blood bank?"

A. The primary function of the Blood Safety and Quality Regulations 2005 (as amended) is to safeguard patient health by ensuring that blood and blood components for transfusion meet the required quality and safety standards. It is not expected that emergency patient treatment should be either compromised or delayed due to the completion of the various Regulatory requirements imposed by these Regulations. It is, however, expected that the necessary records relating to traceability, haemovigilence reporting and other specific requirements which ensure compliance with these Regulations, be completed in full as soon as practicable following the transfusion event.

In the case of traceability of blood or blood components transferred with a patient under emergency situations to another hospital, it may not be appropriate to place the responsibility for maintaining traceability records upon the transfusion laboratory of the receiving hospital, particularly where this laboratory may not be aware of the delivery of the blood on site (e.g. where transfusion takes place in Theatre in emergency treatment situations). In these situations it is expected (unless otherwise described in an agreement approved by both the supplying and receiving sites) that the supplying transfusion laboratory will maintain the traceability records as required by the Regulations. Confirmation of final fate should be obtained by liaison between the transfusion laboratories of the supplying and receiving sites.

Blood transferred with a patient to a different hospital for non-emergency transfusions should be documented within the established receipt systems at the receiving site (e.g. within the transfusion laboratory, if applicable), to facilitate the timely recording of traceability information.

Further information recieved from MHRA in May 2008

The supplying transfusion lab should be able to identify that the traceability information for a particular unit was missing, and should investigate as to the reason. This would indicate the patient transfer, and then by liaison with clinical staff at the receiving hospital, could verify the final fate of the component.