A colleague reports that the nursing policy at their hospital clearly indicates that if a patient experiences a possible transfusion reaction, a physician must order the transfusion to be discontinued and initiate the transfusion reaction investigation. Upon being ordered, nursing will send to the laboratory the blood bag and attached transfusion set, and a request for the laboratory to initiate a transfusion reaction investigation. A sample of the first urine voided is sent to the lab, and a specimen is collected to perform a DAT and a check for hemolysis. The inquiring colleague's local laboratory policy mirrors the nursing policy, in that it also states that a physician must initiate the transfusion reaction investigation. Interestingly, the inquiring colleague states that although a physician is responsible for ordering a transfusion reaction investigation, there are no Medical Staff rules and regulations that address this local requirement. The nursing and laboratory policies are now being questioned because a nurse notified the blood bank laboratory that a physician had been notified that a patient experienced a transfusion reaction (the patient became nauseated and the blood pressure went up) during the transfusion of 225 mL of leukocyte-reduced packed cells. The doctor ordered the transfusion to be discontinued, but did not want to initiate a transfusion reaction investigation. The physician indicated that he was satisfied that the patient experienced fluid overload, and that a laboratory investigation was unnecessary. The above situation was presented to the laboratory director who indicated that if the clinical laboratory scientist (medical technologist) had knowledge of the patient's adverse reaction during transfusion, the technologist should initiate a transfusion reaction investigation, including asking for the blood bag and collecting a specimen for investigation. Since this is not written in their policy, the inquiring colleague is not comfortable with a medical technologist initiating such an investigation. On the other hand, it is their policy to instruct a transfusion to be stopped and a workup to be initiated if during the course of laboratory testing a medical technologist discovers an error or some other finding that is likely to cause patient harm. In such a case they would immediately notify a Pathologist, the patient's physician, and the Laboratory Director. If the discovered error related to a unit of blood that might be in the process of transfusion, they would order the blood to be discontinued and returned to the Transfusion Service for a full investigation. The inquiring colleague wonders if others face a similar scenario, and if so, how do they deal with it.

The following responses have been received.

ADDENDA Aug. 18, 2003

1. A colleague in Texas reports that at her facility, they, too, had a similar "rule" that a physician had to initiate a transfusion reaction workup before it could be performed. However, she alleges that JCAHO inspectors questioned the policy as allowing "too much deviation in standard of patient care". Consequently, she reports that they changed their policy. Now, whenever a nurse notices any one of a number of symptoms from a published list of transfusion reaction symptoms, he/she stops the transfusion, leaves saline running, calls the lab and calls the physician. The physician may elect to keep the transfusion going or stop it completely, but a "workup" is still initiated by the first symptom noticed; the lab does a clerical check and a DAT even if the blood is still running. The Pathologist reviews all of these workups except urticarial-only reactions. This policy has been in effect for approximately five years and the physicians do not feel their authority is being usurped since they can decide whether to continue or stop the transfusion and what medications to give. She reports that this paradigm allows for all patients to be observed during transfusion according to a written protocol and for each "reaction" to be documented accordingly.

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator