A colleague in California reports that she is interested in learn how other hospitals evaluate acute reactions to transfusion that are 'unreported' by the clinical staff to the hospital transfusion service laboratory. Her laboratory performs audits of 'clinical records' pertaining to transfusions, and they look for evidence of febrile, hyper/hypotensive, and other reactions that occur in association with transfusion, but which are not reported to the lab. They have found several examples of what appear to be 'unreported' reactions. She points out that item 7.4.2 of the Standards for Blood Banks and Transfusion Services 23rd edition states: "Adverse events that are suspected to be transfusion related shall be evaluated promptly" and the 42 CFR 493.1271 states: (e) Investigation of transfusion reactions. (1) According to its established procedures, the laboratory that performs compatibility testing, or issues blood or blood products, must promptly investigate all transfusion reactions occurring in facilities for which it has investigational responsibility and make recommendations to the medical staff regarding improvements in transfusion procedures. She acknowledges that it takes a substantial amount of work to discover and follow up each missed reaction.  She wonders if other hospitals screen medical records for 'unreported' transfusion reactions, and if so, what is their mechanism for this review and what is the follow up for the cases that are discovered?

The following comments have been received.

ADDENDA Mar. 14, 2006

1. A colleague at a 1000+ bed hospital in the Midwest comments that in their study entitled "Unreported Transfusion Reactions in A Very Large Community Academic Teaching Hospital" which appears in Transfusion 45:3S, Sept 2005, only 5% of events meeting the hospital's criteria of a possible transfusion reaction were reported by nursing. Stringent retrospective review of transfusion records (n=16,606) produced 1,703 "unrecognized reactions" which had not been reported to the blood bank. Follow-up of the patients' charts did not reveal any "significant" unreported "reactions". Most of the unreported "reactions" during transfusion were limited to blood pressure changes of at least 30 mm Hg (either an increase or decrease).

2. A colleague in California reports that at her hospital, they perform audits of 'clinical records' pertaining to transfusions and have found several examples of what appear to be 'unreported' reactions. They have extreme difficulty in convincing nurses that blood pressure changes must be reported as possible transfusion reactions. They have used a change (up or down) of 40 mm Hg in either the systolic or diastolic pressure as criteria for a possible reaction.

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