GUIDELINES FOR THE CARE OF A PATIENT RECEIVING A BLOOD
TRANSFUSION Reference Date approved Approving Body Matrons Forum Supporting Policy/ Working in New Ways (WINW) Package
Implementation date November 2011 Supersedes Version1 Consultation undertaken Nursing Practice Guidelines Group, Ward Sisters/Charge Nurses, Practice Development Matrons (PDMs), Clinical Leads, Matrons.
Target audience
Document derivation / evidence base: See main references Review Date November 2014 Lead Executive Director of Nursing Author/Lead Manager Steven Cliffe & Hayley Bond Further Guidance/Information Hospital Transfusion Committee Distribution:
Ward Sisters/Charge Nurses, PDMs, Clinical Leads, Matrons, Nursing Practice Guidelines Group (includes University of Nottingham representative), Clinical Quality, Risk and Safety Manager, Trust Intranet.
This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using the guidelines after the review date.
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Contents
SECTION TITLE PAGE Introduction 3
1.0 Prior to transfusion 4 1.1 Patient Information 4 1.2 Prescribing 4 1.3 Venous Access 5 1.4 Identity 5 1.5 Observations 5 1.6 Collection & Transport of Blood 6 1.7 Bedside Checking Procedure 9
"This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date."
These guidelines must be read in conjunction with the local Blood Transfusion policy (NUH 2011, CL/CGP/008).
INTRODUCTION:
A red blood cell transfusion may be indicated for the following reasons:
Acute blood loss due to trauma or surgery To increase the oxygen carrying capacity of the blood in some types of anaemia To provide treatment and support for some types of chronic or malignant disorders e.g. rheumatoid arthritis, thalassaemia, sickle cell disease and leukaemia
PRINCIPLES OF CARE
See General Principles for All Procedures
GUIDELINES FOR THE CARE OF A PATIENT RECEIVING A BLOOD TRANSFUSION
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1.0 PRIOR TO TRANSFUSION
PRINCIPLE RATIONALE
1.1
Patient information
Ensure the patient has received the appropriate leaflet Will I need a blood transfusion Information for patients needing irradiated blood Children receiving a Blood Transfusion, a parents guide in addition, is aware of all the potential risks and benefits involved in having a transfusion. Stocks of leaflets are available from the National Blood Service (01865 440042)
Patients have a right to receive good quality, written information to enable them to give informed consent to any invasive procedure.
Prescribing A clear rational for transfusion should be recorded on the blood transfusion record sheet and the patients notes. It should also be documented in the patients notes that the patient has verbally consented to the transfusion. Ensure the blood is correctly prescribed, by a registered medical practitioner, on the Trust Blood Transfusion Record Chart. Whenever possible blood transfusions should not be administered overnight, except where the patient's condition makes this necessary.
Complies with National Safety Patient Agency (NPSA), Safety of Blood Tissues & Organs (SaBTO), Better Blood Transfusion 3 (DoH circular) for the appropriateness of transfusion Handbook of Transfusion Medicine (4 th
Complies with local policy and National recommendations from the Serious Hazards of Transfusion (SHOT) scheme.
Frequent observations disturb the patient's rest. Reduced staffing levels and difficulty observing the patient in a light dimmed environment make detection of a possible reaction more difficult.
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1.3
Venous access
Ensure the patient has a patent peripheral cannula or central venous catheter in situ. There is no maximum or minimum size of peripheral cannula as this depends on the size of the patient's vein and the speed at which the blood is to be infused. Intravenous Administration of Medications- NUH Intranet
Ensures there are no delays in administration. Blood should be administered immediately after being removed from the issue fridge to decrease the possibility of potential bacterial contaminants Handbook of Transfusion Medicine 2007. If not used immediately & transfusion cannot be completed within the 4 hours of removal from issue fridge, it must be returned and handed to a member of blood bank staff. DO NOT PLACE IN FRIDGE Out of hours - Bleep Blood Transfusion Laboratory staff.
1.4
Identity
The patient should already have an identity band on. If not, attach one to the patient that states the patients last name, first name, gender, date of birth, NHS Number &/or hospital identification number. . POSITIVE PATIENT IDENTIFICATION Check these details are correct with the patient verbally (if possible) and the patients hospital notes
All patients must have an identification wristband - NPSA safer practice notice 11. (SPN) NHS number is the preferred number NPSA SPN 001
The identity of patients MUST be confirmed prior to commencing a blood transfusion. This reduces the risk associated with wrong patient errors Positive Identification of Patients Procedure CL/CGP/037
1.5
Observation
Check and record the baseline observations - temperature, pulse, blood pressure, respiration rate, SpO 2 , and consciousness level (AVPU or GCS) and Early warning Score should be taken, prior to collecting and commencing the blood transfusion. (No more than 1 hour previous)
Do not send staff to collect blood before these have been done
Baseline observations are required to identify any possible deviations from the patients norm. If baseline observations are not within normal limits, medical staff may wish to review and delay transfusion. To comply with N.I.C.E. Guidance (2007)
Confidential enquiry into patient outcome and death [NCEPOD 2005] had reported that in critically ill medical patients, the respiratory rate is an important indicator of deterioration. May waste unit if transfusion delayed
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1.6
Collection and Transport of Blood
Only members of staff who have been trained in the collection of blood from the blood fridge may do so. This is also applicable to bank and agency staff. It is the responsibility of the nurse in charge to ensure the individual has been trained, before sending them to collect blood. ONLY in life threatening haemorrhage will Blood Bank staff help in the collection of products, providing the member of staff has their own ID and ID details of the patient
To collect blood the preferred documentation is a completed Transfusion Record Sheet. For blood being moved to theatre satellite fridges the Theatre Collection Sheet could also be used
City Staff ONLY Never use another member of staff's bar-coded issue card to remove a unit of blood.
Withdrawing of an incorrect component from the blood fridge remains the most common error in incidents where the incorrect blood is transfused (SHOT 2006). Adequate checking procedures are therefore essential to the process. NPSA SPN 14 Handbook of Transfusion Medicine (4 th
See Training & Development on home page of NUH Website or email Transfusion Practitioners for details of training courses available.
Using another individual's bar-coded issue card is a disciplinary offence. It also means that you could be held accountable for a mistake made by another member of staff. 1.6a
All staff Document the required details on the signing-out sheet at QMC Campus or the electronic sign out system at City Campus.
Laboratory staff have to audit the movement of all blood units in line with local and national guidelines to ensure compliance with cold chain documentation - Blood Safety & Quality Regulations 2005 (BSQR) Non-compliance will result in the wastage of blood products.
1.6b
The compatibility form is collected with the first unit of blood and should be filed in patients notes. Never use to collect or check Blood Products
Information on the compatibility form and a donor unit label will be identical. However, this may not correspond with the details in the patient's medical records for which the blood is prescribed. NPSA SPN-14
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1.6c
Remove the unit of blood from the blood bank fridge, ensuring the door is firmly closed. Units of blood should be used in the order in which they appear on the compatibility form. No more than one unit of blood per patient should be collected at any one time unless specifically requested by medical staff.
Blood must be stored between 2- 6 C in order to remain suitable for transfusion. The use of blood is rationalised so units are used before their expiry and are not wasted. Never store blood in a ward fridge. Only validated Blood fridges can be used.
1.6d
When using a satellite blood fridge, ensure all units of blood are booked in and out, so that the bag number and date/time of entering into and removal from fridge are recorded. This information is to be recorded on the Cold Chain Management Form supplied with the units.
Ensures an accurate record of the movement of blood units to satellite fridges, which complies with British Standard 4376 that maintains a consistent recorded temperature. Satellite Fridge at City Campus are: Main Theatre CICU Theatre Toghill Ward Maternity Theatre (Used for Emergency O Negative units ONLY)
Satellite Fridge at QMC Campus: Main Theatres
National guidelines require this in case of adverse incidents occurring - BSQR 2005. Best Practice WITHDRAWING OF BLOOD FROM BLOOD BANK
Withdrawing of an incorrect component from the blood fridge remains the most common error in incidents where the incorrect blood is transfused (SHOT 2006). Adequate checking procedures are therefore essential to the process.
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1.6e
At the point of collection; Ensure that the unit of blood is correctly identified by checking the patients identification, taken to the blood fridge (usually Transfusion record sheet), with the full name, date of birth, gender and NHS or hospital number on the unit Check the unit is in date Ensure that the donation numbers (the G number) is the same on both labels (front and reverse) of the unit Check that this number also matches the number of the donation which is being signed out Check special requirements Usually the donor unit and the patient unit are the same blood group but on occasions, they are not. If you are not happy with this, check with the transfusion laboratory staff
Ensures that the correct unit of blood is removed for the correct patient. NPSA SPN-14 Handbook of Transfusion Medicine (4 th
Expired blood MUST NOT be administered under any circumstances. BSQR 2005
CMV & Irradiated products On occasions, patients blood group may not be available and Laboratory staff will select appropriate group. Rh (D) Negative can be safely given to Rh (D) Positive patients. Only in emergency situations will Rh (D) Positive blood be issued to Rh (D) Negative women of child bearing age (<60 years) 1.6f Check for leakage by gently squeezing the bag and observing along the seams for exudates.
The blood may be contaminated if the bag is not intact. If any leakage is present return bag to a member of the blood bank staff immediately in a container that prevents spillage. 1.6g Check unit for discolouration. If dark coloured or black, this could indicate presence of infection. If unit is discoloured return bag to blood bank staff immediately. 1.6h If any detail, however minor, does not match. DO NOT take back to clinical area. Seek advice from Laboratory Staff Telephone & Bleep numbers are available to contact Laboratory Staff at the issue fridge
Best Practice RETURNING BLOOD UNITS TO BLOOD BANK
If a unit of blood has been out of the fridge for 30mins or more, it must be returned to the blood bank and handed to a member of the laboratory staff. It must NOT, under any circumstances, be placed back in the blood fridge. If the unit has been out for more than 30 minutes, but transfusion is imminent, the unit may be used, but transfusion must be completed within 4 hours of removal from the fridge.
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1.7
1.7a
Bedside Checking procedure
Each unit of blood must be checked independently by two people prior to the administration of the unit. This check must be made beside the patient, i.e. at bedside or theatre trolley. The following staff are able to check blood: Registered Nurse/Midwife, Registered Medical Practitioner, and Registered Operating Department Practitioner. A student nurse/midwife may act as a second checker provided they have the necessary knowledge to perform the role e.g. drug administration training
Complies with NUH Transfusion Policy 2011, NPSA SPN-14
To ensure the correct patient receives the correct blood. If a patient is transfused with an incompatible unit of blood, there is a high risk of an acute haemolytic reaction, which could prove to be fatal.
Handbook of Transfusion Medicine (4 th
Edition) 2007 (stationary office) Section 2 page 20 Must understand reasons for checking patient ID at the bedside
1.7b
The following details (last name, first name, date of birth, gender and patient identification number) must be checked and found to be identical by: Positively identifying the patients using verbal questioning i.e. Tell me your full name and date of birth and checking the details are the same on the ID band & Transfusion Record Sheet. If verbal confirmation is not possible, the ID band must be carefully checked. If possible, check with parents for paediatric patients who are unable to respond Checking the blood transfusion compatibility form for order of unit transfusion ONLY Checking that the compatibility label attached to the unit of blood, has the same donation number (the G number) as the label on the front of the unit
To prevent an error in administration.
NO ID band NO transfusion
Compatibility form should not be used as final part of identity check NPSA SPN- 14
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1.7c The unit of blood must be checked for compliance with any special requirements on the transfusion record sheet and patients notes E.g. Cytomegalovirus (CMV) status.
The unit of blood must be checked to ensure it has not passed its expiry
Complete the Transfusion Record Sheet details time collected (if on the sheet) start and finish times of the transfusion and signature of the person who set up the transfusion & witness. Donation number of unit being transfused The blood bank may not have been informed of any special requirements. It is imperative these requirements are checked and this is the last opportunity to do so.
The Nation Blood Service (NBS) only accept liability for the product up to the expiry date at 23:59 as printed on the unit To facilitate patient transfusion records BSQR 2005 1.7d If any discrepancies are found during the bedside identity checking procedure then consult with the blood transfusion laboratory staff before commencing the transfusion. (Ward does not need to match) Depending on the discrepancy, the unit may be authorised for transfusion or returned to the laboratory.
Each unit of blood must be checked using the above procedure. All details checked at all stages must match exactly. Mis-spelling or incorrect details are not acceptable.
Complete the transfusion record sheet with both the signatures of the person administering the blood transfusion and the checker. Ensure the donation numbers (the G numbers) are accurately recorded including check digit and pack number. This should also include the start and stop time of administration of each unit of blood. Outcome of transfusion? Was there a reaction? At the end of the transfusion episode the Transfusion Record Sheet must be returned promptly to Blood Transfusion so final fate of unit can be recorded The most important single cause of mis- transfusion is failure of some aspect of the bedside checking procedure immediately prior to administering the transfusion (Annual Report, Serious Hazards of Transfusion, 2006).
Required by BSQR 2005 to show final fate of every unit transfused which is kept by the Blood Bank for 30 years to aid in look back for Transfusion Transmitted Infections
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2. DURING TRANSFUSION
PRINCIPLE RATIONALE
2.1
2.1a
Administration
Blood must be administered using a designated blood administration set which has a filter with a minimum size of 200 microns.
It is not necessary to prime the giving set routinely. If it is required, use 0.9% sodium chloride intravenous infusion
The majority of the filter chamber should be filled when priming the administration set.
The amount of blood units able to be transfused through one administration set is subject to manufacturer's guidance, although usually, this is two units per administration set.
The 200m filter on a standard blood administration giving set traps large aggregates. A leucocyte filter is no longer required when administering blood as blood is now leucocyte depleted at source to remove the risk of transferring viruses.
Covering the majority of the filter with blood when priming the line facilitates maximum use of the filter.
If too many units are transfused through an administration set, the filter can become clogged and not work effectively. Best Practice: The final patient ID check at the bedside is the last opportunity to detect an error
A failure to undertake the formal ID check of the component with patient at the patient at the bedside: Puts the patient at risk Breaches professional standards & guideline (Positive Identification of Patients Procedure CL/CGP/037, NPSA SPN-14)
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2.1b
Wash hands and apply apron and gloves
Connect the administration set according to the procedure for the 'preparation of an intravenous infusion and care of a patient receiving an intravenous infusion'
In accordance with Trust policy and to prevent cross infection
To promote safe evidence-based practice. Intravenous Administration of Medications (2010)
2.1c
If multiple venous access is present then ensure that blood is not administered at the same time as any other drug likely to also cause an anaphylactic reaction. If single venous access is present, do not introduce other drugs into the blood administration set unless absolutely necessary and directed by a clinician.
Under no circumstances must a drug be added to the blood pack.
If administration of a drug is unavoidable then ensure the line is flushed with 0.9% sodium chloride before and after the drug administration.
Ensures that it is possible to accurately identify which infusion/drug is responsible for reaction, facilitating appropriate action to be taken if necessary. Introducing other drugs to the administration set increases the possibility of contamination or blood clotting/haemolysing in the line
2.1d
Ensure the blood is administered at the prescribed rate, which should not exceed 4 hours from removal of cold storage.
Electronic infusion devices may damage blood cells and should not be used unless specified as safe by the manufacturer.
Fluid overload may occur if the blood is infused too quickly. There is increased risk of bacterial growth after 4 hours. Handbook of Transfusion Medicine (4 th
Edition) 2007 (stationary office)
Best Practice TRANSFUSION TIMES
Blood should not be transfused for more than 4 hours from removal from cold storage as there is increased risk of bacterial growth after this time. Discontinue unit if infusion has taken more than 4 hours even if unit of blood is not completely finished. Standard intravenous cannulas are suitable for blood components infusion.
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2.2
2.2a
Observations
A full set of observations - temperature, pulse, blood pressure, respiration rate, SpO 2 , consciousness level (AVPU or GCS) and early warning score should be taken prior to the transfusion starting.
The nurse/midwife should remain with the patient for the first 5 minutes after each unit of blood is commenced.
A full set of vital signs should be performed and recorded (as indicated above) 15 minutes after the start of each unit.
The patient should be asked to inform the nurse/midwife if he/she feels at all 'different' during the transfusion.
Unconscious patients are less easy to monitor for possible reaction. As a result, frequent observation patterns should be maintained, according to the patient's condition.
This is the same for each new unit of blood commenced.
A temperature increase of up to 1.5 above the baseline recording is treated with anti- pyretics and slowing the transfusion rate. Any rise above this and the transfusion must be stopped and a Doctor informed.
NB. If baseline is raised above normal at the start of the transfusion and then continues to rise, inform medical staff.
To establish a baseline (NICE ref CG50 2007)
Severe reactions can occur during the first 5 minutes of transfusion.
An increase in temperature and pulse may be a sign of incompatibility.
Patients may complain of feeling unwell prior to any changes in temperature and pulse that may indicate a reaction. (Handbook of Transfusion Medicine 2007) The patient is unable to alert the staff if they feel unwell.
Each unit is from a different donor and poses the same potential risks.
Patients can react to non red cell components within the unit of blood and this can cause a small raise in temperature.
Contact Blood Bank
Hyperpyrexia can cause serious complications.
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2.2b The patient should not leave the ward unless supervised by staff competent to deal with transfusion reactions/anaphylaxis while the transfusion is in progress Un-supervised patients may have a life threatening reaction at any time during the transfusion episode
2.2c During the transfusion observe the patient for signs of the following; Flushing Itching Fever Vomiting Diarrhoea Urticaria Pain at or near transfusion site Rigor Backache Throat swelling Haemoglobinuria Collapse Circulatory failure. Bleeding at infusion site
If any of these occur, the transfusion should be stopped and a member of the medical staff should be contacted immediately.
Undertake a complete set of vital signs as outlined above and commence Early Warning Scores or Paediatric equivalent every 5 minutes. Further management depends on the type and severity of the reaction and may be suggested by the medical staff. Further routine observations during the transfusion of each blood unit are dictated by the patients condition. Any of these symptoms could be an indication of a transfusion reaction or anaphylaxis. Urgent intervention is required as transfusion reactions can be fatal. Refer to Anaphylaxis policy.
To prevent further deterioration of patient condition and to treat symptoms.
2.2d. If the decision is to stop the transfusion, disconnect the administration set immediately and withdraw blood (approx 2mls) from the venous access device. Flush with 0.9% sodium chloride to maintain its patency. Full observations should be taken and recorded as stated above.
Withdrawing blood from the venous access device ensures that no more of the transfused blood enters the patient's circulatory system.
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Best Practice:
Observations during & after the transfusion is essential for the early detection of any adverse events or reactions
Adverse reaction can occur with all blood products
Additions observations should be made if an adverse reaction is suspected
Monitoring the unconscious/compromised or paediatric patient: Be alert as they may not be able to report symptoms of a transfusion reaction NEONATES may become hypothermic rather than febrile in response to a transfusion reaction
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PRINCIPLE RATIONALE
2.3
2.3a
Adverse reaction
If a severe reaction is suspected following review by medical staff then; Report to the hospital's blood bank Seek Haematology Medical Advice if required Complete an incident report form (DATIX) Change the blood administration set and maintain venous access using an infusion of 0.9% sodium chloride. Return of the implicated unit and the giving set to the blood bank Obtain blood samples from the patient as per blood bank instructions Complete and return Transfusion Reaction Ward Form that is sent to you by Blood Bank as soon as possible
To prevent transfusion of any further suspect blood.
To enable investigation of the incident
It is now legal requirement that all serious adverse reactions be reported to the blood bank for onward reporting to the government (Blood Safety and Quality Regulations 2005), SHOT & Serious Adverse Blood Reactions & Events (SABRE) Analysis of the unit of blood and administration set may identify contaminants and their point of origin. These results may guide medical intervention in the patient's care.
2.3b
The blood unit and administration set should be transported back to blood bank using a waterproof container such as a sealed clinical waste bag appropriately labelled. DO NOT USE AIRTUBE SYSTEM
Use of shallow or permeable containers, such as plastic trays or kidney receivers, may allow spillage of blood.
Sharps bins should NOT be used under any circumstances
2.3c
Follow Hospital Transfusion Policy 2011 for reporting adverse transfusion reactions.
Frequent observations of temperature, pulse, blood pressure, respiration rate, SpO 2 , and consciousness level (AVPU or GCS) and Early warning Score urine output and colour should be continued until the patient's condition is stable.
To comply with N.I.C.E Guidance (2007)
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3. POST TRANSFUSION
PRINCIPLE RATIONALE
3.1
Observations
Once the transfusion is completed, a set of observations should be completed and documented.
Complete the blood transfusion prescription and record sheet, including the outcome and return the top copy to blood bank.
To provide a baseline for future monitoring.
To comply with N.I.C.E Guidance (2007)
Law (BSQR 2005) requires 100% traceability of all blood products. These records must be kept for 30 years 3.2 Disconnection
Once the transfusion is completed, disconnect the blood administration set and flush the access device, or change for a fluid administration set if required.
Do not attach an infusion bag of 0.9% sodium chloride directly to the blood administration set to 'flush' through the blood.
Infusing any fluid other than blood through the administration set after a transfusion encourages particles that have been trapped by the 200 microns filter to enter the patient's bloodstream.
For further information, see Guide to IV Therapy 4th Edition. 3.3 Disposal of waste
The empty blood bag should be discarded according to the hospital policy for the disposal of clinical waste. Part empty bags still attached to an administration set should be disposed of together in a new sharps bin containing absorbent gelling agent, for example, Vernagel .
To avoid spillage.
There is no requirement to store empty bags providing the product has been transfused without adverse event
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Best Practice: The person responsible for the transfusion must check: The reason for transfusion is documented in the case notes The patient has received information about the transfusion There is a signature to confirm the pre-transfusion checks have been completed The start & finish time & date is recorded for each unit transfused There is a permanent record of the transfusion episode in the patients medical notes The full completed top copy of the Transfusion Record sheet is returned to Blood Transfusion
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Equality and Diversity Statement
All patients, employees and members of the public should be treated fairly and with respect, regardless of age, disability, gender, marital status, membership or non-membership of a trade union, race, religion, domestic circumstances, sexual orientation, ethnic or national origin, social & employment status, HIV status, or gender re-assignment.
All trust polices and trust wide procedures must comply with the relevant legislation (non-exhaustive list) where applicable:
Equal Pay Act (1970 and amended 1983) Sex Discrimination Act (1975 amended 1986) Race Relations (Amendment) Act 2000 Disability Discrimination Act (1995) Employment Relations Act (1999) Rehabilitation of Offenders Act (1974) Human Rights Act (1998) Trade Union and Labour Relations (Consolidation) Act 1999 Code of Practice on Age Diversity in Employment (1999) Part Time Workers - Prevention of Less Favourable Treatment Regulations (2000) Civil Partnership Act 2004 Fixed Term Employees - Prevention of Less Favourable Treatment Regulations (2001) Employment Equality (Sexual Orientation) Regulations 2003 Employment Equality (Religion or Belief) Regulations 2003 Employment Equality (Age) Regulations 2006 Equality Act (Sexual Orientation) Regulations 2007
Equality Impact Assessment Statement
NUH is committed to ensuring that none of its policies, procedures, services, projects or functions discriminates unlawfully. In order to ensure this commitment all policies, procedures, services, projects or functions will undergo an Equality Impact Assessment.
Reviews of Equality Impact Assessments will be conducted inline with the review of the policy, procedure, service, project or function
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REFERENCES
Anaphylaxis-Guidelines for the Treatment of (2010) http://nuhnet/nursing_and_midwifery/preceptorship/Pages/ClinicalSkills.aspx
Better Blood Transfusion 2 and 3 HSC 2002/009 and HSC 2007/001 http://www.dh.gov.uk/en/Publicationandstatistics/Lettersandcirculars/Healthse rvicecirculars/DH_080613
Blood Safety & Quality Regulations (2005) SI 2005/50 http://www.legislation.gov.uk/uksi/2005/50/contents/made
Intravenous Administration of Medications (2010) http://nuhnet/nursing_and_midwifery/preceptorship/Pages/ClinicalSkills.aspx
Infection Prevention and Control Policy (2011) (CL/GP/031) http://nuhnet/diagnostics_clinical_support/infection_prevention_control/Pages /Policies.aspx
Kelsey P, Murphy M.F., Atterbury C.L.J., Chapman J.F., Lumley K.S., McClelland D.B.L., Stockley R., Thomas D. & Wilkinson J., (1999) The Administration of Blood and Blood Components and the Management of Transfused Patients Transfusion Medicine Vol 9 pp 227-238
National Confidential Enquiry into Patient Outcome & Death NCEPOD (2005) An acute problem? http://www.ncepod.org.uk/2005aap.htm
NICE Guidance CG50, 2007, Acutely Ill Patients in Hospital http://www.nice.org.uk/nicemedia/pdf/CG50FullGuidance.pdf
Nottingham University Hospitals NHS Trust, Transfusion Policy CL/CGP/008
NPSA Safer Practice Notice 14 Competency Assessment (2006) http://www.npsa.nhs.uk