OCTOBER 2011 REVISED NVBSP BLOOD MONITOPRING AND

HOSPITAL BLOOD TRANSFUSION REPORT

REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF HEALTH
CENTER FOR HEALTH DEVELOPMENT for NORTHERN LUZON
REGION I BLOOD SERVICES NETWORK
NATIONAL VOLUNTARY BLOOD SERVICE PROGRAM

NVBSP BLOOD MONITORING REPORT

LA UNION MEDICAL DIAGNOSTIC CENTER & HOSPITAL
Name of Hospital
Ancheta St. city of San Fernando, La Union
Address
607-83-39 / 607-83-40
Contact No.
Period Covered
I. TOTAL NO. OF DONOR
Total number of donor s interviewed/examined: _________________
Temporary Deferment
Low
Other Medical
HGB
Conditions

Travel and other

Reasons

Permanent Deferment:
High Risk Behavior others

Total

II.A. TOTAL BLOOD COLLECTION (Number of Donors Bled): __________________

Mobile
Deposit
Bled for
BLOOD
Volunteer/
Family/
Exchange
Blood
for
Emergency
PRODUCT
Walk-in
Replacement
transfusion
Donation
Elective
Case
N

Autologous
Transfusion
N

Total

Paid
Donors
N

Fresh Whole
Blood
N New Donors; R - Repeat donors
II.B. APHERESIS
BLOOD
PRODUCT

Voluntary
N

Family/
Replacement
N

Paid
Donors
N

Others
(Specify)

Platelet
III. DISTRIBUTION OF BLOOD DONORS BY AGE AND GENDER
Gender
Age
Male
Female
16-17
18-24
25-44
45-64
65 and above
IV. SEROLOGICAL TESTING FOR TRANSFUSION-TRANSMISSIBLE INFECTIONS (TTIs)
Result of Confirmatory Test
NO OF BLOOD UNITS TESTED
(RITM)
REACTIVE
NONNOT
RESULTS
TEST
REACTIVE
NEGATIVE
POSITIVE
SCREENED
RESULTS
Strip
EIA
HBsAg
HCV
VDRL/RPR
Malaria
HIV
TOTAL
Reason/s for not screening the blood unit/s
Non-availability of Reagents/Kits

E Situation

Staff Shortage

Equipment Failure/Power Loss

Others

Total

OCTOBER 2011 REVISED NVBSP BLOOD MONITOPRING AND

HOSPITAL BLOOD TRANSFUSION REPORT

V. NO. OF BLOOD BAGS DISCARDED/ NOT USED

Blood Product

Expired

Positive
TTIs

Contaminated

Processing
Problem
(unsuccessful
bleeding)

Storage
Problem
(Hemolyzed)

Transport
Problem

Others

Packed Red Cell

Fresh Frozen Plasma
Cryosupernate
Cryoprecipitate
Platelet
TOTAL

VI. COMPONENT FRACTION CAPABILITY

a. How many WHOLE BLOOD donations were separated into components? _______________.
b. No. of blood components prepared for Whole Blood donations? _____________________
Blood Products

Refrigerated Centrifuge

Apheresis

Fresh Whole Blood/Whole Blood

Packed Red Cell/Washed RBC
Fresh Frozen Plasma/Plasma
Cryosupernate
Cryoprecipitate
Platelet
Others
VII. INVENTORY OF BLOOD PRODUCTS RECEIVED
BLOOD UNITS FROM
Blood Products

DOH
(Government Hospital)

Local Government Unit

(LGU) Hospital

Philippine
Red Cross

Private
Hospital

Fresh Whole
Blood /Whole Blood
Packed Red Cell
Fresh Frozen Plasma
Platelet
Cryoprecipitate /
Cryosupernate
Washed RBC
Others
TOTAL
VIII. CLASSIFICATION OF BLOOD SERVICE FACILITY
a)

Ownership
Government
Private

b) Institutional Character
Hospital-based
Non-hospital-based

c) Service Capability
Blood Center (BC)
Blood Station (BS)
Blood Collecting Unit (BCU)
BCU/BS
Hospital Blood Bank
Others _________________________

IX. Do you have standard operating procedures (SOP) or local written instruction and records of the following?

Commercial Blood
Bank

OCTOBER 2011 REVISED NVBSP BLOOD MONITOPRING AND

HOSPITAL BLOOD TRANSFUSION REPORT

Yes

No

1. Blood donor recruitment

2. Pre-donation counseling and donor selection
3. Blood collection and donor care
4. Post donation counseling
5. Laboratory screening and blood donations for
Transfusion Transmissible Infections (TTIs)
6. Blood Group Serology Testing of blood donations
7. Preparation of blood components
8. Compatibility testing
9. Transfusion of blood to patients
X. Do you participate in an external quality assessment scheme/external evaluation on performance for:
Yes

No

1. Transfusion-transmissible infections
2. Blood serology
3. Compatibility Testing

IX. INVENTORY OF BLOOD PRODUCT DISPENSED TO OTHER BLOOD SERVICE FACILITY

NAME OF HOSPITAL
FWB/WB PRBC/WRBC PLATELET

FFP/CRYOSUP/CRYOPPT

TOTAL
X. MOBILE BLOOD DONATION
Location

Number of Mobile Blood Donation

Total No. of Donors Bled

Prepared by:

Noted by:

Approved by:

Medical Technologist

Sheldon Steven C. Aquino, MD, DPBP

Head of Laboratory

______________________
Hospital Administrator

OCTOBER 2011 REVISED NVBSP BLOOD MONITOPRING AND

HOSPITAL BLOOD TRANSFUSION REPORT

HOSPITAL BLOOD TRANSFUSION COMMITTEE REPORT

I.

BLOOD COMPONENT TRANSFUSION

BLOOD
Products

SURGERY

OB-GYNE

MEDICINE

PEDIA

ORTHO

ENT

OTHERS

TOTAL

Fresh Whole Blood

Whole Blood
Packed red Cell
Fresh Frozen Plasma
Cryosupernate
Cryoprecipitate
Platelet
Washed RBC
Others
Total
II.
Age

PATIENTS TRANSFUSED ACCORDING TO AGE AND GENDER

Gender
Male

Female

<5
5-14
15-44
45-59
60 and above
III.
BLOOD
PRODUCTS

CROSSMATCHED/TRANSFUSED RATIO
SURGERY
OB-GYNE
MEDICINE PEDIA
# of
# of
# of
# of
# of
# of
# of
# of
units units units units units units units units

ORTHO
# of
# of
units units

ENT
# of
units

xmatc
hed

xmatc
hed

xmatc
hed

Trans
Fuse
d

xmatc
hed

Trans
fused

xmatc
hed

Trans
fused

xmatc
hed

Trans
fused

FWB
Whole
Blood
Packed
RBC
Total
C:T
IV.
A.
B.
C.
D.
E.

No. of patients whom blood was requested ______________________

No. of patients who received blood _________________
No. of surgical cancellations due to unavailability of blood ___________
No. of cases delayed due to unavailability of blood _________________
No. of death due to unavailability of blood ________________________

Trans
fused

# of
units
Trans
fused

OTHERS
# of
# of
units units

TOTAL
# of
# of
units units

xmatc
hed

xmatc
hed

Trans
fused

Trans
fused

OCTOBER 2011 REVISED NVBSP BLOOD MONITOPRING AND

HOSPITAL BLOOD TRANSFUSION REPORT

V.
A. No. of errors dealing with laboratory processes
a. Labeling _________
c. Testing ________
b. Preparation _______
d. Issuance __________
B. Incomplete Collection __________
C. No. of units prepared and held for patients but not used
(the difference between # of units x-matched and transfused)
Surgery _______
OB-Gyne ______
Medicine ______
VI.

Orthopedics _________
Pediatrics ___________
ENT _______________

Urology _________
Hemodialysis _____
Others __________

REQUEST FOR BLOOD AND COMPATIBILITY TESTING

A. Routine ___________________________________________
B. Emergency
a. Crossmatched three phases _____________________
b. Crossmatched saline and albumin only _________
c. Crossmatched saline phase only ______________
d. ABO Type specific uncrossmatched __________
e. Group O Uncrossmatched blood ____________
VII.

BLOOD TRANSFUSION REACTION

(Please use extra sheet if necessary)

Date
Transfused

Blood
Product

Patients Working Diagnosis.

Signs and Symptoms of

Transfusion Reaction

Summary/Impression
Transfusion Reaction
Investigation

OCTOBER 2011 REVISED NVBSP BLOOD MONITOPRING AND

HOSPITAL BLOOD TRANSFUSION REPORT

VIII.

Hospital Blood Transfusion Cases Per Department (Diagnosis)

(Please use extra sheet if necessary)
Department
Diagnosis

Prepared by:

Medical Technologist

Noted by:
Sheldon Steven C. Aquino, MD, DPBP
Head of Laboratory

# of Cases

Approved by:
______________________
Hospital Administrator