New Jersey Department of Health

Clinical Laboratory Improvement Service

PO Box 361

Trenton, NJ 08625-0361

TRANSFUSION REACTION REPORT

________________________________________________________________________________________________

INSTRUCTIONS:

1.	Pursuant to N.J.A.C. 8:8-5.2, blood banks must report hemolytic and/or delayed hemolytic and other known or suspected life-threatening transfusion reactions within 10 days of the occurrence using this form; and must report known and/or suspected fatal transfusion reactions by telephone call to 609‑406-6829 by the next working day after the day the event occurs, with written follow-up within 10 days of the occurrence, using this form.

2.	Forward the original copy of the report to the address listed above; retain a copy for your records.

3.	If there are any questions, contact the Blood Bank Unit at 609-406-6829.

4.	Briefly summarize the events leading to the reaction below. Attach copies of the transfusion reaction work‑up performed.

5.	Describe corrective action(s) taken to prevent adverse event from recurring.

Name of Blood Bank

Telephone Number

Date of Transfusion

Time of Transfusion

Day, Date and Time of Reaction

Amount of Blood Transfused

Patient ABO Group

Donor ABO Group

Location of Patient at Time of Reaction

Patient Name

Patient Age

Diagnosis

Type of Reaction
Fatal	Non-Fatal
Hemolytic
Anaphylactic
Delayed Hemolytic
a. Amount of time after transfusion
b. Specify antibody, if applicable
Bacterial (List Organism)
Describe Events Leading to the Reaction and Corrective Action Taken (If more space is needed attach additional sheets.)

Date Reported

Name of Blood Bank Director

Signature of Blood Bank Director
CL-44

JUL 12	Forward completed Report to address listed above; retain a copy for your records.

CL-44, Transfusion Reaction Report

CL-44, blood bank, transfusion reaction report, clinical lab improvement service

ewhite

2008-01-16

NJDOH