Complete and return no later than 10 calendar days following the end of a calendar month.
Clinical Laboratory Program
99 Chauncy Street
Boston, MA 02111
Directions for Completion of Page 1 of Form
Blood Bank Demographics
Complete all information:
- Facility number (page 1 and 2), Name, Address, Bed Size
- Names of Blood Bank Medical Director and Supervisor
- Blood Bank phone number (include area code)
Adverse Effects of Transfusions
Disease Transmission sources
- Enter the source of the units (BB donor program, American Red Cross, National Blood Exchange, etc.) - include state if from a non-Massachusetts source
Reactions - Immediate
- Immediate Hemolytic Reactions due to ABO incompatibility
Enter on this report and also report immediately to the DPH - Clinical Laboratory Program [617-753-8060 or 6732]
- Immediate Hemolytic Reaction (non-ABO)
Enter total number and specify the antibody which caused the reaction
Reactions - Other
- Enter total number of each reaction type
Use the American Association of Blood Bank definitions found in the most recent edition of the Technical Manual
Source of Products
- Enter the overall estimated percent for each source listed
A serious incident report MUST be filed with the DPH whenever a patient receives an incorrect unit of blood even if it is type compatible (e.g., unit given to wrong patient, wrong patient receives blood, patient mistyped). Information relating to the reporting of a serious incident can be found in Circular Letter: DHCQ-12-98-385 - Hospital Reporting of Serious Incidents, which was sent to all hospitals in December 1998.
Directions for Completion of Page 2 of Form
Statistics are to be reported by the Blood Bank providing crossmatch services and should include all units for all facilities supported by the Blood Bank (e.g., hospitals, End Stage Renal Dialysis facilities, Transitional Care Units, etc.). Facilities which provided Transfusion Services ONLY should not report their statistics on this form.
Blood Bank - a facility equipped and staffed to procure, draw, process, store and/or dispense blood and/or blood components.
Transfusion service - a service designed, equipped and staffed to dispense and/or administer blood and/or blood components.
Complete the data by entering one digit per box, ending in the farthest right hand box.
0 0 , 0 6 4
Transfused units: blood product units which are not wasted and/or transferred. Report individually as Transfused; Transfused Washed; or Transfused Autologous.
Wasted Units: blood product units which are not transfused and/or transferred. Report as Wasted [includes washed, if applicable] and Wasted Autologous.
Transferred Units: report number of units received into inventory and then transferred to another Blood Bank.
Total Crossmatches: report number of crossmatches [full, immediate spin, computer] performed for Whole Blood and Red Blood Cells.
Total Irradiated Blood Products: report the total number of units of blood/blood components that were irradiated before infusion. Irradiated units are not to be counted separately in the above reported statistics.