Hemovigilance Adverse Reaction - Unknown Transfusion Reaction (with modified GISAB questions in tracked changes)

57.319_HV-AR-UNK_OMB.docx

[NCEZID] The National Healthcare Safety Network (NHSN)

Hemovigilance Adverse Reaction - Unknown Transfusion Reaction (with modified GISAB questions in tracked changes)

OMB: 0920-0666

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NHSN Logo Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/22

www.cdc.gov/nhsn

Hemovigilance Module

Adverse Reaction

Unknown Transfusion Reaction

*Required for saving

*Facility ID#: _________

NHSN Adverse Reaction #: __________


Patient Information

*Patient ID: ___________________

*Gender:

M

F

Other

*Date of Birth: ____/____/_____

Sex at Birth: M F Unknown





Gender Identity (Specify):________

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


Transitional ABO / Rh +

Transitional ABO / Rh -


Transitional ABO / Transitional Rh

Group A/Transitional Rh

Group B/Transitional Rh

Group O/Transitional Rh

Group AB/Transitional Rh

Patient Medical History


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


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


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


Code: ______________

Description: __________________________________________________


Code: ______________

Description: __________________________________________________


Code: ______________

Description: _________________________________________________


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: __________________________________________________


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).


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: ________________________________________________




Additional Information __________________________________________________________________________________



Transfusion History




Has the patient received a previous transfusion?

YES

NO

UNKNOWN




Blood Product:

WB

RBC

Platelet

Plasma

Cryoprecipitate

Granulocyte




Date of Transfusion:

____/____/_____

UNKNOWN




Was the patient’s adverse reaction transfusion-related?

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 #: ________________



Investigation Results


* Unknown



Diagnosis of case: ______________________________________________________________________





List tests relevant to reaction investigation:


Test name:

________________

Testing date:

_______________

Test result:

_________________



Test name:

________________

Testing date:

_______________

Test result:

_________________



Other signs and symptoms: (check all that apply)



Generalized:

Chills/rigors

Fever

Nausea/vomiting



Cardiovascular:

Blood pressure decrease

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?



No treatment required

Symptomatic treatment only



Hospitalization, inlcuding prolonged hospitalization

Life-threatening reaction



Disability and/or incapacitation

Congenital anomaly or birth defect(s) of the fetus



Other medically important conditions

Death

Unknown or not stated



*Imputability



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



Conclusive evidence exists that the adverse reaction can be attributed to the transfusion.



Evidence is clearly in favor of attributing the adverse reaction to the transfusion.



Evidence is indeterminate for attributing the adverse reaction to the transfusion or an alternate cause.



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.



Did the transfusion occur at your facility?

YES

NO




Module-generated Designations



NOTE: 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 _________________________________________________________






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

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


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

(Required for Infection and TRALI)

*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

Custom Fields

Label


Label


_______________

______/______/________

________________

______/______/________

_______________

___________________

________________

__________________





Comments



CDC 57.319 Rev.2, v9.2 Page 7 of 7


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title57.319
SubjectNHSN OMB Forms 2020
AuthorCDC/NCZEID/DHQP
File Modified0000-00-00
File Created2024-09-16

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