PvERS: the Pharmacovigilance Electronic Reporting System: Transfusions

MINISTRY OF HEALTH

PHARMACY AND POISONS BOARD

P.O. Box 27663-00506 NAIROBI

Tel: +254795743049

Email: pv@pharmacyboardkenya.org

ADVERSE TRANSFUSION REACTION FORM

Tip: Fields marked with * are mandatory

Form ID: new

In the event of a reaction following transfusion of blood or blood products please complete this form and send it to the laboratory with the specimens listed below.

PATIENT INFORMATION

Patient Name *

DATE OF BIRTH*

--OR--

Age group

GENDER *

MaleFemale clear!

Patient No.

County

Donor Number

Student/National ID Number

Home Phone No.

Cell Phone No.

Residence

(county)

Clinic Venue

Clinic Code

Diagnosis

Ward

Pre-transfusion HB

Reason for transfusion

Current Medication

Obstetric History

(N/A, Gravid.., Para...))

Previous Transfusion

YesNo clear!

Previous Reactions

YesNo clear!

REACTION INFORMATION

Vital Signs

At Start

During (15min)

At Stop

Low Volume

> 1 Venepuncture

Hematoma

Faint

MildModerateSevere clear!

Specimens collected

10mls post-transfusion whole blood from patient from plain bottle 2mls of blood in EDTA bottle 10mls First Void Urine The blood that reacted together with the attached transfusion set All empty blood bags of already transfused unit

Recipient’s blood supernatant:

Hemolysis

PresentAbsentEquivocal clear!

If present

MildModerateMarked clear!

Recipient’s blood:

Agglutination

PresentAbsent clear!

Haematological results:

WBC

RBC

HCT

MCV

MCH

MCHC

PLT

Film

RBC

WBC

PLT

Donor blood supernatant:

Agglutination

PresentAbsent clear!

Age of donor pack

Culture donor pack

Culture recipient blood

8. Compatibility testing recipient serum (pretransfusion sample) and donor cells (pack) (Attach print out if applicable)

Compatible

Saline Rt

Saline 37

AHG

Albumin 37

Incompatible

clear!

If negative enzyme treated cells

Result

In case of blood group O transfused to A or B or AB individual: results of:

Anti A titres

Anti B titres

Urinalysis

Evaluation

Was the medicine side effects related to transfusion?

YesNoInconclusive clear!

Do you have pictures or documents that you would like to send to PPB? click on the button to add them:

#	File	Text Description

Name of Initial reporter *

E-MAIL ADDRESS *

Cadre/designation *

PHONE NO.*

Date of report *

Name

E-MAIL ADDRESS

Cadre/designation

PHONE NO.

Date of Submission

MINISTRY OF HEALTH

PHARMACY AND POISONS BOARD

P.O. Box 27663-00506 NAIROBI

Tel: +254795743049

Email: pv@pharmacyboardkenya.org

ADVERSE TRANSFUSION REACTION FORM

Form ID: new

PATIENT INFORMATION

--OR--

REACTION INFORMATION

Vital Signs

COMPONENT INFORMATION

Specimens collected

LAB INVESTIGATION: (BTU)

Recipient’s blood supernatant:

Recipient’s blood:

Haematological results:

Film

Donor blood supernatant:

Compatible

Incompatible

Do you have pictures or documents that you would like to send to PPB? click on the button to add them:

Is the person submitting different from reporter?

MINISTRY OF HEALTH

PHARMACY AND POISONS BOARD

P.O. Box 27663-00506 NAIROBI

Tel: +254795743049

Email: pv@pharmacyboardkenya.org

ADVERSE TRANSFUSION REACTION FORM

Form ID: new

PATIENT INFORMATION

--OR--

REACTION INFORMATION

Vital Signs

COMPONENT INFORMATION Add

Specimens collected

LAB INVESTIGATION: (BTU)

Recipient’s blood supernatant:

Recipient’s blood:

Haematological results:

Film

Donor blood supernatant:

Compatible

Incompatible

Do you have pictures or documents that you would like to send to PPB? click on the button to add them:

Is the person submitting different from reporter?

COMPONENT INFORMATION