Why do transfusion safety checks matter?
Blood transfusion can save lives, and the UK blood supply is very safe from the point of view of infection. The main risks now come from errors in the process, transfusions that were not needed, and reactions such as fluid overload. Serious Hazards of Transfusion (SHOT), the UK's independent haemovigilance scheme, reviews reported incidents every year, and its reports repeatedly show that failures in patient identification and checking still cause serious harm.
An ABO-incompatible red cell transfusion can cause severe haemolysis, kidney failure and death. Many people are involved in a single transfusion: the prescriber, the person who takes the sample, the laboratory, the person who collects the unit and the person who gives it. An error at any stage can lead to the wrong blood reaching the wrong patient.
When is a blood transfusion needed?
The decision should rest on clinical assessment, not a haemoglobin number alone. Consider the cause of anaemia, symptoms, bleeding, other conditions and alternatives such as iron, vitamin B12 or folate. Patient blood management aims to use the patient's own blood well and avoid unnecessary transfusion.
| Patient group (NICE NG24) | Threshold | Target after transfusion |
|---|---|---|
| Adults not actively bleeding, without acute coronary syndrome | Haemoglobin 70 g/L | 70 to 90 g/L |
| Adults with acute coronary syndrome | Haemoglobin 80 g/L | 80 to 100 g/L |
| Major haemorrhage or regular transfusion for chronic anaemia | Individualised | Individualised |
For adults who are not actively bleeding, NICE recommends giving a single unit of red cells, then reassessing clinically and rechecking the haemoglobin before giving more. This avoids over-transfusion, which matters especially in small or older patients.
Consent and information
Valid consent should be obtained and documented before a non-urgent transfusion. SaBTO guidance on consent for transfusion emphasises shared decision-making. Explain the reason and benefits, the risks, the alternatives, what will happen and what symptoms to report, and that receiving a transfusion can affect whether someone can donate blood in future (check the current UK blood services rules). Respect a refusal, including from many Jehovah's Witnesses, record it clearly and seek early advice on alternatives. In an emergency, a transfusion can be given in a patient's best interests if they lack capacity, unless there is a valid and applicable advance decision refusing it; tell them afterwards.
What is positive patient identification in transfusion?
Positive patient identification is the single most important safety step. It means the patient tells you who they are, rather than confirming a name you say.
- Ask, do not tell: Ask the patient to state their full name and date of birth. Do not ask 'Are you John Smith?', because a confused or anxious person may simply agree.
- Check the wristband: Name, date of birth and unique identifier (NHS or hospital number) must match exactly what the patient said and what is on the request or label. If the patient cannot answer, use the wristband and follow local policy.
- At sampling: Bleed one patient at a time and label the tube at the bedside immediately, by hand or with a bedside printer linked to the wristband. Never pre-label tubes or label them away from the patient.
- At collection: Take documentation with the patient's identifiers to the blood fridge and check it against the component label. Only trained, competency-assessed staff should collect.
- At administration: At the bedside, match the patient, the wristband, the component label and the prescription.
A wrong blood in tube (WBIT) error happens when the blood in a sample tube belongs to someone other than the person named on the label. If the laboratory does not detect it, the patient may receive blood that is incompatible with their real group. This is why many hospitals require two separate samples before issuing group-specific red cells to a patient with no previous record.
What are the bedside checks before starting a unit?
SHOT recommends a structured bedside checklist, completed with the patient immediately before connecting each unit and never away from the bedside. Your hospital's checklist may differ in layout, but it should cover the same points.
- The component: right type, not damaged, leaking, clotted or discoloured, and within its expiry.
- Consent is documented.
- Positive patient identification: the patient states full name and date of birth.
- The wristband, component label, compatibility tag and prescription all match, including unit number and blood group.
- Special requirements, such as irradiated components, are met.
- Baseline observations are recorded.
Two nurses check the unit against the prescription at the nurses' station, then one takes it to bay 3 and says, 'Mr Patel, here's your blood,' before connecting it.
The nurse takes the unit and prescription to the bedside, asks the patient to state his full name and date of birth, checks these against his wristband, the unit label and the prescription, confirms the unit number, group, expiry and that irradiated blood was requested and supplied, checks consent is recorded, takes baseline observations and then connects the unit.
What observations are needed during a transfusion?
Most serious acute reactions happen in the first 15 minutes of a unit. Use a giving set with an integral blood filter, do not add medicines to the component, and complete each red cell unit within the time limit in your local policy (British Society for Haematology guidance gives 4 hours from removal from temperature-controlled storage).
| When | What |
|---|---|
| Before each unit (no more than 60 minutes before) | Pulse, blood pressure, temperature, respiratory rate and oxygen saturation |
| 15 minutes after starting each unit | Repeat observations and compare with baseline |
| During the unit | Visual observation and further observations as indicated or required locally |
| End of each unit (within 60 minutes of completion) | Repeat observations |
| After the transfusion | Tell the patient what to report, as delayed reactions can occur |
Watch the patient, not only the numbers. Feeling anxious or that 'something is wrong', pain at the cannula site, chest or loin pain, breathlessness, flushing or shivering can be early signs of a serious reaction. Unconscious patients need especially close monitoring. Record the unit number, start and finish times and who gave it, and complete the traceability step your laboratory requires.
What are the main types of transfusion reaction?
| Reaction | Typical features | Notes |
|---|---|---|
| Acute haemolytic (often ABO incompatibility) | Fever, rigors, low blood pressure, loin or back pain, pain at the infusion site, dark urine, collapse | Medical emergency, usually caused by an identification error |
| Febrile non-haemolytic | Fever, sometimes rigors, without other features | Common and usually mild, but can be the start of something serious |
| Allergic and anaphylaxis | Itching and hives; or wheeze, swelling and low blood pressure | Treat anaphylaxis using Resuscitation Council UK guidance |
| TACO (circulatory overload) | Breathlessness, low saturations, raised blood pressure and heart rate, crackles, oedema | SHOT identifies TACO as the most common cause of transfusion-related death and major morbidity |
| TRALI (acute lung injury) | Severe breathlessness and hypoxia during or soon after transfusion, often with low blood pressure | Needs urgent critical care input |
| Bacterial contamination | Fever, rigors and collapse, often early | Rare; more often linked to platelets |
SHOT recommends a formal TACO risk assessment before transfusion wherever possible. Risk is higher in older or frail people, those with low body weight, heart failure, kidney disease or a positive fluid balance. Options to reduce risk include giving one unit and reassessing, slowing the rate, monitoring fluid balance and considering a diuretic with medical advice.
What should you do if you suspect a transfusion reaction?
- Stop the transfusion: Stop immediately but keep the venous access. Do not throw away the bag or giving set.
- Assess with ABCDE and call for help: Call a doctor, or the emergency team if the patient is seriously unwell. Treat as needed, including the anaphylaxis algorithm.
- Recheck identity: Check the patient's identity against the component label and paperwork. If there is a mismatch, another patient may be at risk, so tell the laboratory at once.
- Contact the transfusion laboratory: Follow their instructions on samples and returning the unit and giving set.
- Decide about continuing: For a mild reaction, a senior clinician may restart more slowly with closer monitoring. For moderate or severe reactions, do not restart.
- Document and report: Record the reaction, actions and outcome and complete an incident report. The hospital transfusion team reports to SHOT and, where required, to the MHRA through SABRE.
Arthur is 86, weighs 50 kg and has heart failure. His haemoglobin is 67 g/L and two units are prescribed back to back overnight, with no TACO risk assessment. Three hours in he becomes breathless, with saturations of 87% on air, a raised blood pressure and crackles at both bases. The staff nurse, Bea, stops the transfusion, sits him up, gives oxygen, calls the doctor, checks his identity against the unit and informs the laboratory. He improves with treatment. At the review, the team agrees that a TACO assessment, a single unit followed by reassessment and daytime transfusion would probably have prevented this, and they add the TACO checklist to the ward's transfusion bundle.
Keeping your transfusion practice safe
UK hospitals require staff involved in transfusion to complete training and competency assessments for their role, such as sampling, collection and administration. Keep yours up to date and follow your local transfusion policy and hospital transfusion team's advice.
Our Blood Transfusion Safety course covers deciding to transfuse, consent, positive patient identification, bedside checks, monitoring, recognising and managing reactions, and emergencies, with a case study and reflection. If you are reflecting on a transfusion incident that involved you, take advice from your defence organisation or trade union before writing statements.
Frequently asked questions
What checks are done before a blood transfusion?
At the bedside, immediately before connecting each unit: check the component for damage, leaks, clots, discolouration and expiry; confirm consent is documented; ask the patient to state their full name and date of birth; match these with the wristband, component label, compatibility tag and prescription; confirm any special requirements; and record baseline observations.
How often should observations be done during a blood transfusion?
UK guidance sets a minimum of baseline observations within 60 minutes before each unit, repeat observations 15 minutes after starting each unit, observations within 60 minutes of finishing each unit, and further observations whenever clinically indicated. Pulse, blood pressure, temperature, respiratory rate and oxygen saturation should be included. Follow your local policy.
What is the first thing to do in a transfusion reaction?
Stop the transfusion immediately while keeping the cannula in place, then assess the patient using ABCDE and call for medical help. Do not discard the bag or giving set. Recheck the patient's identity against the unit, contact the transfusion laboratory and follow their instructions. Anaphylaxis should be treated using Resuscitation Council UK guidance.
What is TACO in blood transfusion?
TACO stands for transfusion-associated circulatory overload. It causes breathlessness, low oxygen levels, raised blood pressure and heart rate, and crackles, often in older or frail patients or those with heart or kidney disease. SHOT reports it as the most common cause of transfusion-related death and major morbidity and recommends a TACO risk assessment before transfusion.
What is a wrong blood in tube error?
A wrong blood in tube (WBIT) error is when the blood in a sample tube does not belong to the patient named on the label, for example because the tube was labelled away from the bedside. It can lead to incompatible blood being issued. Prevent it by bleeding one patient at a time and labelling at the bedside after positive identification.
How long can a unit of red cells run for?
British Society for Haematology guidance says a red cell transfusion should be completed within 4 hours of the unit being removed from temperature-controlled storage. Many patients need units to run more quickly than this, while others at risk of fluid overload may need a slower rate. Follow your local transfusion policy and the prescription.
Does a patient need to consent to a blood transfusion?
Yes. Valid consent should be obtained and documented before a non-urgent transfusion, including the reason, risks, alternatives and what to expect. Patients can refuse. In an emergency, if the patient lacks capacity, transfusion can be given in their best interests unless there is a valid and applicable advance decision refusing it.
Related courses
Blood Transfusion Safety
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Sources and further reading
- Blood transfusion (NG24). National Institute for Health and Care Excellence.
- Guideline on the administration of blood components. British Society for Haematology.
- Annual SHOT Report: key messages and recommendations. Serious Hazards of Transfusion (SHOT).
- Guidelines on patient consent for blood transfusion. Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO).
- Emergency treatment of anaphylaxis. Resuscitation Council UK.
- Blood Safety and Quality Regulations 2005. legislation.gov.uk.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
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