Forms and Labeling
  Ordering Transfusions
Transfusion Procedure
  Audit Procedure
  Adult Transfusions
  Pediatric Transfusions
  Informed Consent
  OR Schedule
  Massive Transfusion
  Trauma Activated Transfusion Algorithm (TATA)
  Bloodloc System
  Block Release Protocol
  Available Components
Transfusion Medicine Service Transfusion Procedure

Further Information Is Available By Contacting The Medical Director of the Transfusion Medicine Service: Zbigniew.M.Szczepiorkowski, M.D. or the Blood Bank Medical Director, Nancy Dunbar M.D.

Refer to the Transfusion Committee Policy, Blood Transfusion and Blood Component Administration, for complete procedural information.

Following are policies relating to the transfusion of blood at Dartmouth Hitchcock Medical Center.
  1. There is no need to call the Blood Bank when a Prepare and Transfuse Order for any blood product (except albumin) is placed by the provider. If the order is for red cells, consult eDH to determine if the patient has a current Type and Screen as determined by the "Spec OD" result- if so, the red cells are ready for pick-up. If there is a delay in the availability of RBC’s you will be notified by the Blood Bank. If the order is for plasma, platelets or cryoprecipitate the Blood Bank prepares the product and notifies you when ready for pick-up.
  2. Use eD-H to request transportation for blood component pick up or call transportation services at 5-5580 during downtimes or use a unit based runner to pick up the blood component. The individual picking up the component(s) from the Blood Bank must present with their employee identification badge and will provide the following information on a slip of paper ("pink" pick-up slips are available on patient care units or from stores) to ensure the correct component(s) for the correct patient is taken to the transfusing site:

    • Recipient's full name
    • Recipient's DHMC Medical Record Number
    • Type of product requested

  3. Albumin must be requested by a phone call to the Blood Bank using the information in the MAR of the electronic medical record. Provide the correct product requested to Blood Bank at time of pick up. (i.e. albumin 25% 50 mL, 2 bottles, etc.)
  4. No blood is to be put into unit/ward refrigerators. If blood cannot be transfused promptly after it has come to the floor it must be returned to the Blood Bank.

  5. Blood for only one patient can be picked up at one time to reduce the potential of a patient receiving the wrong unit of blood/blood component.
  6. No more than one unit of blood for any patient will be released from the lab at a time unless the patient is actively bleeding. During bleeding emergencies, the Transfusion Medicine Service will be notified by the Blood Bank to provide assistance, if necessary.
  7. A temperature indicator device will be attached to emergency release units and to each unit going to the OR to ensure that the unit temperature does not exceed 6°C. If the indicator dot has turned red, the unit has exceeded 6°C and may not be returned to the Blood Bank inventory. The unit may still be transfused to the patient as long as the transfusion is completed within four hours from the time of dispense. All non-transfused units should be promptly returned to the Blood Bank.
  8. Do not request blood components until you are ready to transfuse. Products that are returned without temperature monitoring devices must be discarded.

  9. Blood transfusion may be started by licensed physicians, transfusionist certified RNs, Certified Perfusionists or EMT/paramedics following standard hospital procedures.
  10. If the blood lock device does not open by using the code on the patient's wristband, the product must be immediately returned to the Blood Bank and the Blood Bank should be notified by phone at 5-7207. A new sample may be required before transfusion can be given.


    Check the following information on the patient's ID band, component administration record label, and blood product container:
    • Patient's full name
    • DHMC Medical Record Number
    • Date of Birth
    • Component unit number
    • Donor ABO Group and Rh Type
    • Patient ABO Group and Rh Type
    • Results of compatibility testing when appropriate
    • Unit expiration date/time

    If any error is detected in the verification and/or identification process, immediately contact the Blood Bank at 5-7207. Do not initiate transfusion until all discrepancies have been satisfactorily resolved.

    In appropriate spaces of the component administration record label in certain areas, during downtime procedures or in the electronic medical record (EMR) indicate:

    • Date and time transfusion is started
    • Signature of Transfusionist
    • Signature of an appropriate staff member who has reviewed and confirmed positive identification of patient to blood product and accompanying component administration record label
    • Pre-transfusion vital signs within 1 hour prior to the initiation of the transfusion.

    During actual transfusion, obtain a second set of vital signs at 15 minutes into procedure and enter these results onto the component administration record label or EMR.

    At completion of the transfusion:
    • Obtain post-transfusion vital signs within 1 hour and enter these on the component administration record label or EMR
    • Enter date and time transfusion was completed
    • Enter amount of product transfused

    On completion of the above, enter the chart copy of the component administration record label in the patient's paper medical record on the transfusion sheet.

Blood may be run through a primary set, secondary set, or Y-type administration set with normal saline. An appropriate filter is required. Blood may not be run through any solution other than normal saline because of the danger of causing clotting or damage to cellular elements. No medication may be added to the blood or blood component.

Inpatients with normal cardiovascular status should be infused blood at a rate specified by the ordering provider. In most instances, this will require two to four hours for red cells. Should very slow infusion be necessary the Blood Bank should be asked to divide the unit into aliquots which can be stored at controlled temperatures until required. Careful monitoring of the patient is essential.

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