Accurate patient identification and sample labelling is critical and the laboratory operates a zero tolerance policy for samples that are incorrectly labelled or are missing the minimum patient identifiers.

The minimum information on all samples are:

• Surname
• Forename
• Date of birth
• Hospital number

Samples must also be signed by the person performing the venepuncture, dated and timed.

It is the responsibility of the person taking the blood sample to positively identify the patient and label it correctly at the patient’s side. Incorrect or missing information will lead to the sample being rejected and a subsequent delay in availability of blood components.

There are 2 ways of labelling blood transfusion samples; via the Electronic Blood Tracking System (EBTS) PDA or by hand writing, it is preferable and safer to use the PDA if available.

Samples labelled by the PDA must not have any amendments on the PDA printed label – the date/time and signature of the person taking the blood is recorded electronically.

Patient consent:

 NOTE – All procedures carried out on a patient need the informed consent of the patient.

For most routine laboratory procedures, consent can be inferred when the patient presents himself or herself at a laboratory, or other suitable area, within a primary or secondary care setting, with a request form and willingly submits to the usual collecting procedure.

The laboratory infers informed consent has been obtained when samples are received. It is the responsibility of the clinician requesting the test to ensure that informed
consent has been obtained.

This consent includes notification to third parties where required by law for example under
the Health Protection (Notification) Regulations 2010: we are required to notify any infection
of public health significance to local public health department as mandated by the regulation.
Please ensure your patient is aware of this before submission of samples for testing.

NNUH – all samples must be accompanied by a WebIce generated request form (or manual request forms if WebIce is down).

See Blood Transfusion ICE Requesting User Guide (Trust Docs ID:13770)

JPUH – all samples must be accompanied by a WebIce generated request form (or manual request forms if WebIce is down).

QEH – Manual request forms (ICE request forms being implemented Summer 2022)  

Guide to changing internet explorer margins for all ice forms

The transport of samples from GP surgeries or other primary care locations is carried out by the Logistics service staff who will collect all samples from dedicated collection points. Samples from within the hospital can be transported to Pathology either by the Pneumatic Tube System (PTS) if suitable or by a porter.  For urgent samples ward staff are required to arrange delivery to the laboratory. Samples must first be placed in the plastic sample bags together with the completed request form.

The safe transport of specimens to the laboratory is the responsibility of the requesting doctor or carrier. Laboratory responsibility for the sample begins when it has arrived at the laboratory. 

• All items MUST be sent in the carriers provided. 
• Samples MUST not be placed directly into the carriers. ALL Pathology samples MUST be placed in specimen bags and the lids of all items with the potential to leak (fluids etc.) tightly secured BEFORE placing them in the carriers.
• Do not cram samples/items into the carrier as this may lead to breakage/leakage and system failure.
• Only one carrier at a time should be placed in a delivery station.
• Ensure that carriers are closed securely at both ends to avoid them jamming in the tube network.
• If any defect is noticed with the operation of the air-tube systems please notify the laboratory at the earliest opportunity.

NNUH  & QEH – The pneumatic tube systems are for the transport of Blood Sciences and Blood Transfusion specimens to the laboratories only – NO microbiology samples allowed. 

JPUH – The pneumatic tube systems are for the transport of Blood Sciences and Blood Transfusion, and microbiology samples to the laboratories only. 

The air-tube system should NOT to be used for:

• Danger of Infection samples
• Unrepeatable samples

Medical officers responsible for the care of patients have a duty of care towards other members of staff – therefore all samples from patients who are known to have, or strongly suspected of having the conditions noted below must be identified. 

• Creutzfeldt – Jakob disease (CJD)

• Viral haemorrhagic fever (VHF) of any type

• Microorganisms, (biological agents) in Hazard Group 3 or 4
• Pyrexia of unknown origin (PUO) recently returned from Africa
• Hepatitis B and/or C and HIV

 Medical staff should ensure that appropriate information, including relevant travel history, is provided in order to alert laboratory staff of potential dangers. Clinical details supplied on sample request forms must contain clear information regarding the nature of the test being requested and sufficient detail to inform laboratory staff upon the safety precautions they need to take in order to process the sample without risk of infection.

If, during patient intervention, further information becomes available that has implications for the safety of laboratory staff this must be communicated immediately to the laboratory so that appropriate steps regarding containment can be taken.

All 3 transfusion laboratories provide the following blood components and products:

• Red cells
• Platelets
• Fresh Frozen Plasma (FFP)
• Cryoprecipitate
• Anti-D Immunoglobulin (Ig)
• Beriplex (Prothrombin Complex Concentrate – PCC) – not QEH – issued by pharmacy

In addition, NNUH and JPUH issue clotting factors e.g. Factor VIII, Factor IX and vWF.

In order to issue blood components the laboratory must have a valid sample for the patient. A sample is suitable for issuing components for up to 7 days after the sample was taken unless the patient has been pregnant or received a transfusion within the previous 3 months when a sample must be taken and sent for testing within 72 hours of the planned transfusion. 

The check group: in line with national guidelines a check group sample may be required. If the patient has no previous transfusion records at the hospital, then a second sample will be needed to confirm that the correct patient has been bled. If this sample is required, then it should be taken by a different person to the initial sample and must be taken from a separate venepuncture.

When two samples arrive together, or in quick succession, a sample will be regarded as a suitable second sample if it was either:

• taken by a different phlebotomist than the first sample or
• the sample was taken at least 5 minutes after the first sample

NNUH – Requests for red cells must be made through ICE which has been designed to guide appropriate requesting. All urgent requests must be phoned to the laboratory. Once a unit of red cells is issued for a patient it will be available for 24 hours after the date and time required. All other requests for blood components and products are taken over the phone.

Routine red cell transfusions should be one unit at a time with a check Hb in between.

If platelets are required, these need to be requested, by the transfusion laboratory, from NHSBT specifically for the patient. In order to allow for delivery on the routine transport please contact the transfusion laboratory before the order cut off time. One unit of “emergency” platelets is kept on site.

For order cut off times and expected times of delivery click here

Platelets will be returned to stock 8 hours after the date and time requested has passed.

If you require blood components for a patient with a known special requirement e.g. Irradiated blood products or CMV- products, it is important to ensure that the transfusion laboratory is aware of that patient’s needs. If the requirement is new or if the patient has not been treated at the hospital before then the appropriate special requirements request form must be completed and sent to the lab to allow an alert to be created for previous attendances (Trust Docs ID: 1286).

JPUH – Red Cells can be pre-ordered on the request form but for urgent red cells and all other components the laboratory must be telephoned on extension 2443 or 2050, in all cases you will need patient ID and reason for transfusion (for platelets the National Indication (P) Code available on the Authorisation sheet must be provided).

Once a unit of red cells has been issued it will remain available in the issue fridge for 24- 48 hours, dependent on recent transfusion history, before being returned to stock. All other components are returned to stock after 24 hours. If you require a component to continue to be available this must be discussed with the laboratory.

Routine red cell transfusions should be one unit at a time with a check of Hb in between.

When requesting Platelets please ensure that you try to telephone your request to enable delivery within the required time frames. Please click here for JPUH Platelet time frames. One unit of platelets, for emergency use, is kept on site.

If you require blood components for a patient with a known special requirement e.g. Irradiated blood products or CMV- products, it is important to ensure that the transfusion laboratory is aware of that patient’s needs.

QEH – All requests for blood components at QEH must be made by telephone on x3782. The laboratory staff will always ask specific questions about your request including the patient’s weight. This is so that patients are ensured the correct components and interventions.

Routine red cell transfusions should be one unit at a time with a check Hb in between.

One unit of  emergency platelets is kept on site. For other routine platelet orders they should be requested by clinicians via the Transfusion Laboratory before the cut off time to allow for routine delivery. We have one delivery per day. 

Please click here for QEH Platelet time frames

If you require blood components for a patient with a known special requirements e.g. Irradiated blood products or CMV- products, it is important to ensure that the transfusion laboratory is aware of that patient’s needs.

Only staff who have been trained have access to the Blood Fridge to collect donor units, in an emergency (if no trained person available) a person who has not been trained can come down and ask the BMS for help.

In all cases full patient ID (unless collecting emergency group O units) and the red box must be brought down. Failure to do so will result in delay and without patient ID the only product that can be collected are Emergency group O red cells.

Never give your barcode to someone else and ask them to collect – this could result in disciplinary measures being taken.

If emergency group O blood is required, you must contact the laboratory and they will issue O positive in preference to O Negative, in line with patient blood management strategies, if appropriate.

For prophylactic anti-D, Beriplex, and Coagulation factors a completed drug chart must be brought down.

To collect blood components from the transfusion laboratory an EBTS pick up slip must be used. This should be taken to the transfusion issue hatch (East Block, Level One) and given to the laboratory staff who will issue the required components.

If emergency group O blood is required, you must contact the laboratory and they may issue O positive or O negative, in line with patient blood management strategies, if appropriate.

For areas that have a satellite blood fridge only staff who have been appropriately trained can put units in or remove them as per the Trust Guideline for the Storage of Blood Components in and Maintenance of Satellite Blood Fridges (Trust Docs ID: 1074)

For further information on collection and administering blood components please see Trust Policy for the Collection and Return of Blood Components/Products from the Norfolk and Norwich University Hospital Transfusion Laboratory (Trust docs id 1077)

Trust Clinical Policy for Checking Blood Components/Products prior to Administration (Trust docs ID No: 1094)

Blood components can only be collected using the Blood Track kiosks in the Blood Bank Issue room through the Pathology waiting area. Only staff assessed as competent to do so may collect blood using a patient pick up sticker and their own barcode.

Blood should be removed one unit at a time from the issue fridge, scanned out and placed in a blood transport bag available next to the Kiosk.

In an emergency, the laboratory should be notified of the need for Emergency O negative, if no blood is available for the patient, Emergency O negative blood should be taken from the Issue fridge. This does not require a pick up slip as it has not been allocated to an individual, but patient’s details must be recorded on the blood collection report.

There are no satellite blood fridges at the QEH but the QEH maintains a Blood Bank refrigerator at North Cambridgeshire Hospital for use in their Macmillan Alan Hudson Palliative Care Centre.