Form 57.311 Hemovigilance Adverse Reaction - Febrile Non-hemolytic T

The National Healthcare Safety Network (NHSN)

57.312_HV AR-HTR_BLANK.DOCX

57.311_HV AR-FNHTR_BLANK

OMB: 0920-0666

Document [docx]
Download: docx | pdf

NHSN Logo Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn


Hemovigilance Module

Adverse Reaction

Hypotensive Transfusion Reaction

*Required for saving

*Facility ID#: _________

NHSN Adverse Reaction #: __________


Patient Information

*Patient ID: ___________________

*Gender:

M

F

Other

*Date of Birth: ____/____/_____

Social Security #: ______________

Secondary ID: _________________

Medicare #: _________________

Last Name: ___________________

First Name: ____________________

Middle Name: _______________

Ethnicity

Hispanic or Latino

Not Hispanic or Not Latino


Race

American Indian/Alaska Native

Asian

Black or African American


Native Hawaiian/Other Pacific Islander

White

*Blood Group:

A-

A+

B-

B+

AB-

AB+

O-

O+

Blood type not done


Patient Medical History (Use worksheet on page 4 for additional codes and descriptions.)


(part 1) List the patient’s admitting diagnosis. (Use ICD-10 Diagnostic codes/descriptions)


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


(part 2) List the patient’s underlying indication for transfusion. (Use ICD-10 Diagnostic codes/descriptions)


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: _________________________________________________


(part 3) List the patient’s comorbid conditions at the time of the transfusion related to the adverse reaction. (Use ICD-10 Diagnostic codes/descriptions)

UNKNOWN

NONE


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________

Continued >>






Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).


Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333 ATTN: PRA (0920-0666).

CDC 57.312 (Front) Rev 1, v8.8

Hypotensive Transfusion Reaction


Patient Medical History (Use worksheet on page 4 for additional codes and descriptions.)


(part 4) List the patient’s relevant medical procedure including past procedures and procedures to be performed during the current hospital or outpatient stay. (Use ICD-10 Procedure codes/descriptions)

UNKNOWN

NONE


Code: _______________

Description: _____________________________________________


Code: _______________

Description: ________________________________________________


Code: _______________

Description: ____________________________________________


(part 5) Additional Information ________________________________________________________________________


_____________________________________________________________________________________________________


_____________________________________________________________________________________________________

Transfusion History (Use worksheet on page 4 for additional transfusion history.)


Has the patient received a previous transfusion?

YES

NO

UNKNOWN


**If yes, provide information about the transfusion event. If not, skip to Reaction Details section.


Blood Product:

WB

RBC

Platelet

Plasma

Cryoprecipitate

Granulocyte


Date of Transfusion:

____/____/_____

UNKNOWN


Did the patient experience a transfusion adverse reaction?

YES

NO


If yes, provide information about the transfusion adverse reaction.


Type of transfusion adverse reaction:

Allergic

AHTR

DHTR

DSTR

FNHTR


HTR

TTI

PTP

TACO

TAD

TA-GVHD

TRALI

UNKNOWN


OTHER

Specify __________________________________________________________________________

Reaction Details

*Date reaction occurred: ____/____/____

*Time reaction occurred: __ __:__ __

Time unknown

*Facility location where patient was transfused:

______________________________________________

*Is this reaction associated with an incident?

Yes

No

If Yes, Incident #: ________________

After recognition of the transfusion reaction, was the current transfusion:


Continued

Stopped and restarted

Stopped indefinitely


Investigation Results

* Hypotensive transfusion reaction



*Case Definition


Check all that occurred during or within 1 hour of cessation of transfusion:


All other adverse reactions presenting with hypotension are excluded.


Hypotension


Check all that apply:


Hypotension occurs, does not meet the criteria above. Other, more specific reaction definitions do not apply.


None of the above

Continued >>

Hypotensive Transfusion Reaction


Investigation Results (continued)

Other signs and symptoms: (check all that apply)

Generalized:

Chills/rigors

Fever

Nausea/vomiting

Cardiovascular:

Shock

Cutaneous:

Edema

Flushing

Jaundice

Other rash

Pruritus (itching)

Urticaria (hives)

Hemolysis/Hemorrhage:

Disseminated intravascular coagulation

Hemoglobinemia

Positive antibody screen

Pain:

Abdominal pain

Back pain

Flank pain

Infusion site pain

Renal:

Hematuria

Hemoglobinuria

Oliguria

Respiratory:

Bilateral infiltrates on chest x-ray

Bronchospasm

Cough

Hypoxemia

Shortness of breath

Other: (specify) __________________________________________________________________________



*Severity


Did the patient receive or experience any of the following? (Response definitions listed in protocol)


Symptomatic treatment only

Hospitalization, inlcuding prolonged hospitalization


Life-threatening reaction

Disability and/or incapacitation


Congenital anomaly or birth defect(s) of the fetus

Death


Other medically important conditions

Unknown or not stated



*Imputability


Which best describes the relationship between the transfusion and the reaction?


The patient has no other conditions that could explain hypotension.


There are other potential causes present that could explain hypotension, but transfusion is the most likely cause.


Other conditions that could readily explain hypotension are present.


Evidence is clearly in favor of a cause other than the transfusion, but transfusion cannot be excluded.


There is conclusive evidence beyond reasonable doubt of a cause other than the transfusion.


The relationship between the adverse reaction and the transfusion is unknown or not stated.




How did the patient respond the cessation of transfusion and supportive treatment?


Responds rapidly (i.e., within 10 minutes) to cessation of transfusion and supportive treatment.


The patient does not respond rapidly to cessation of transfusion and supportive treatment.



Did the transfusion occur at your facility?

YES

NO



When did the reaction occur in relation to the transfusion?


Occurs less than 15 minutes after the start of the transfusion.


Onset is between 15 minutes after start and 1 hour after cessation of transfusion.





Continued >>

Hypotensive Transfusion Reaction


Investigation Results (continued)

Designations for case definition, severity, and imputability will be automatically assigned in the NHSN application based on responses in the corresponding investigation results section above.

Do you agree with the case definition designation?

YES

NO

Please indicate your designation _________________________________________________________

Do you agree with the severity designation?

YES

NO

Please indicate your designation _________________________________________________________

Do you agree with the imputability designation?

YES

NO

Please indicate your designation _________________________________________________________

Additional Information _____________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________


Patient Treatment


*Did the patient receive treatment for the transfusion reaction?

YES

NO

UNKNOWN


If yes, select treatment(s):


Medication (Select the type of medication)


Antipyretics

Antihistamines

Inotropes/Vasopressors

Bronchodilator

Diuretics


Intravenous Immunoglobulin

Intravenous steroids

Corticosteroids

Antibiotics


Antithymocyte globulin

Cyclosporin

H1 receptor blockers

Other



Volume resuscitation (Intravenous colloids or crystalloids)



Respiratory support (Select the type of support)


Mechanical ventilation

Noninvasive ventilation

Oxygen



Renal replacement therapy (Select the type of therapy)


Hemodialysis

Peritoneal

Continuous Veno-Venous Hemofiltration



Phlebotomy


Other

Specify: ____________________________________________________________



Outcome


*Outcome:

Death

Major or long-term sequelae

Minor or no sequelae

Not determined


Date of Death:

____/____/_____



^*If recipient died, relationship of transfusion to death:


Definite

Probable

Possible

Doubtful

Ruled Out

Not determined


Cause of death:

______________________________________________________


Was an autopsy performed?

Yes

No


Continued >>

Hypotensive Transfusion Reaction


Component Details (Use worksheet on page 4 for additional units.)

*Was a particular unit implicated in (i.e., responsible for) the adverse reaction?

Yes

No

N/A

Transfusion Start and End Date/Time

*Component code (check system used)

Amount transfused at reaction onset

Unit number

*Unit expiration Date/Time

*Blood group of unit

Implicated

Unit?

^IMPLICATED UNIT

____/____/___

ISBT-128

Entire unit

Partial unit

______mL

__ __ __ __ __

___/___/_____

A-

A+

B-

Y

___ ___:_____

Codabar

__ __

____/____/___

___ ___ ___ ___ ___

__ __ __ __ __ __

_____ : _____

B+

AB-

AB+

___ ___:_____

_________________

__ __ __

O-

O+

N/A

____/____/___

ISBT-128

Entire unit

Partial unit

______mL

__ __ __ __ __

___/___/_____

A-

A+

B-

N

___ ___:___ _

Codabar

__ __

____/____/___

___ ___ ___ ___ ___

__ __ __ __ __ __

_____ : _____

B+

AB-

AB+

___ ___:_____

_________________

__ __ __

O-

O+

N/A

____/____/___

ISBT-128

Entire unit

Partial unit

______mL

__ __ __ __ __

___/___/_____

A-

A+

B-

N

___ ___:_____

Codabar

__ __

____/____/___

___ ___ ___ ___ ___

__ __ __ __ __ __

_____ : _____

B+

AB-

AB+

___ ___:___ __

_________________

__ __ __

O-

O+

N/A



Custom Fields

Label


Label


_______________

______/______/________

________________

______/______/________

_______________

___________________

________________

__________________

_______________

___________________

________________

__________________

_______________

___________________

________________

__________________

Comments

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________





Hemovigilance Module

Additional Worksheet

Patient Medical History


(part 1) List the patient’s admitting diagnosis. (Use ICD-10 Diagnostic codes/descriptions)


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________





(part 2) List the patient’s underlying indication for transfusion. (Use ICD-10 Diagnostic codes/descriptions)


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: _________________________________________________


(part 3) List the patient’s comorbid conditions at the time of the transfusion related to the adverse reaction. (Use ICD-10 Diagnostic codes/descriptions)

UNKNOWN

NONE


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


(part 4) List the patient’s relevant medical procedure including past procedures and procedures to be performed during the current hospital or outpatient stay. (Use ICD-10 Procedure codes/descriptions)

UNKNOWN

NONE


Code: _______________

Description: _____________________________________________


Code: _______________

Description: ________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: _______________

Description: ____________________________________________


(part 5) Additional Information ________________________________________________________________________


_____________________________________________________________________________________________________


_____________________________________________________________________________________________________


_____________________________________________________________________________________________________

Hemovigilance Module

Additional Worksheet


Transfusion History


Has the patient received a previous transfusion?

YES

NO


**If yes, provide information about the transfusion event. If not, skip to Reaction Details section.


Blood Product:

WB

RBC

Platelet

Plasma

Cryoprecipitate

Granulocyte


Date of Transfusion:

____/____/_____

UNKNOWN


Did the patient experience a transfusion adverse reaction?

YES

NO


If yes, provide information about the transfusion adverse reaction.


Type of transfusion adverse reaction:

Allergic

AHTR

DHTR

DSTR

FNHTR


HTR

TTI

PTP

TACO

TAD

TA-GVHD

TRALI

UNKNOWN


OTHER

Specify __________________________________________________________________________





Has the patient received a previous transfusion?

YES

NO


**If yes, provide information about the transfusion event. If not, skip to Reaction Details section.


Blood Product:

WB

RBC

Platelet

Plasma

Cryoprecipitate

Granulocyte


Date of Transfusion:

____/____/_____

UNKNOWN


Did the patient experience a transfusion adverse reaction?

YES

NO


If yes, provide information about the transfusion adverse reaction.


Type of transfusion adverse reaction:

Allergic

AHTR

DHTR

DSTR

FNHTR


HTR

TTI

PTP

TACO

TAD

TA-GVHD

TRALI

UNKNOWN


OTHER

Specify __________________________________________________________________________





Has the patient received a previous transfusion?

YES

NO


**If yes, provide information about the transfusion event. If not, skip to Reaction Details section.


Blood Product:

WB

RBC

Platelet

Plasma

Cryoprecipitate

Granulocyte


Date of Transfusion:

____/____/_____

UNKNOWN


Did the patient experience a transfusion adverse reaction?

YES

NO


If yes, provide information about the transfusion adverse reaction.


Type of transfusion adverse reaction:

Allergic

AHTR

DHTR

DSTR

FNHTR


HTR

TTI

PTP

TACO

TAD

TA-GVHD

TRALI

UNKNOWN


OTHER

Specify __________________________________________________________________________







Hemovigilance Module

Additional Worksheet

Component Details

*Was a particular unit implicated in (i.e., responsible for) the adverse reaction?

Yes

No

N/A

Transfusion Start and End Date/Time

*Component code (check system used)

Amount transfused at reaction onset

Unit number

*Unit expiration Date/Time

*Blood group of unit

Implicated

Unit?

____/____/_____

ISBT-128

Entire unit

Partial unit

______mL

__ __ __ __ __

___/___/_____

A-

A+

B-

N

___ ___:___ ___

Codabar

__ __

____/____/_____

___ ___ ___ ___ ___

__ __ __ __ __ __

_____ : _____

B+

AB-

AB+

___ ___:___ ___

_________________

__ __ __

O-

O+

N/A

____/____/_____

ISBT-128

Entire unit

Partial unit

______mL

__ __ __ __ __

___/___/_____

A-

A+

B-

N

___ ___:___ ___

Codabar

__ __

____/____/_____

___ ___ ___ ___ ___

__ __ __ __ __ __

_____ : _____

B+

AB-

AB+

___ ___:___ ___

_________________

__ __ __

O-

O+

N/A

____/____/_____

ISBT-128

Entire unit

Partial unit

______mL

__ __ __ __ __

___/___/_____

A-

A+

B-

N

___ ___:___ ___

Codabar

__ __

____/____/_____

___ ___ ___ ___ ___

__ __ __ __ __ __

_____ : _____

B+

AB-

AB+

___ ___:___ ___

_________________

__ __ __

O-

O+

N/A

____/____/_____

ISBT-128

Entire unit

Partial unit

______mL

__ __ __ __ __

___/___/_____

A-

A+

B-

N

___ ___:___ ___

Codabar

__ __

____/____/_____

___ ___ ___ ___ ___

__ __ __ __ __ __

_____ : _____

B+

AB-

AB+

___ ___:___ ___

_________________

__ __ __

O-

O+

N/A

____/____/_____

ISBT-128

Entire unit

Partial unit

______mL

__ __ __ __ __

___/___/_____

A-

A+

B-

N

___ ___:___ ___

Codabar

__ __

____/____/_____

___ ___ ___ ___ ___

__ __ __ __ __ __

_____ : _____

B+

AB-

AB+

___ ___:___ ___

_________________

__ __ __

O-

O+

N/A

____/____/_____

ISBT-128

Entire unit

Partial unit

______mL

__ __ __ __ __

___/___/_____

A-

A+

B-

N

___ ___:___ ___

Codabar

__ __

____/____/_____

___ ___ ___ ___ ___

__ __ __ __ __ __

_____ : _____

B+

AB-

AB+

___ ___:___ ___

_________________

__ __ __

O-

O+

N/A

____/____/_____

ISBT-128

Entire unit

Partial unit

______mL

__ __ __ __ __

___/___/_____

A-

A+

B-

N

___ ___:___ ___

Codabar

__ __

____/____/_____

___ ___ ___ ___ ___

__ __ __ __ __ __

_____ : _____

B+

AB-

AB+

___ ___:___ ___

_________________

__ __ __

O-

O+

N/A


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