ANNEX II
NOTIFICATION OF SERIOUS ADVERSE REACTIONS
PART A
Rapid notification format for suspected serious adverse reactions
Reporting establishment
Report identification
Reporting date (year/month/day)
Date of transfusion (year/month/day)
Age and sex of recipient
Date of serious adverse reaction (year/month/day)
Serious adverse reaction is related to
—
Whole blood
—
Red blood cells
—
Platelets
—
Plasma
—
Other (specify)
Type of serious adverse reaction(s)
—
Immunological haemolysis due to ABO incompatibility
—
Immunological haemolysis due to other allo-antibody
—
Non-immunological haemolysis
—
Transfusion-transmitted bacterial infection
—
Anaphylaxis/hypersensitivity
—
Transfusion related acute lung injury
—
Transfusion-transmitted viral infection (HBV)
—
Transfusion-transmitted viral infection (HCV)
—
Transfusion-transmitted viral infection (HIV-1/2)
—
Transfusion-transmitted viral infection, Other (specify)
—
Transfusion-transmitted parasitical infection (Malaria)
—
Transfusion-transmitted parasitical infection, Other (specify)
—
Post-transfusion purpura
—
Graft versus host disease
—
Other serious reaction(s) (specify)
Imputability level (NA, 0-3)
PART B
Serious adverse reactions — imputability levels
Imputability levels to assess serious adverse reactions.
Imputability level
Explanation
NA
Not assessable
When there is insufficient data for imputability assessment.
0
Excluded
When there is conclusive evidence beyond reasonable doubt for attributing the adverse reaction to alternative causes.
Unlikely
When the evidence is clearly in favour of attributing the adverse reaction to causes other than the blood or blood components.
1
Possible
When the evidence is indeterminate for attributing adverse reaction either to the blood or blood component or to alternative causes.
2
Likely, Probable
When the evidence is clearly in favour of attributing the adverse reaction to the blood or blood component.
3
Certain
When there is conclusive evidence beyond reasonable doubt for attributing the adverse reaction to the blood or blood component.
PART C
Confirmation format for serious adverse reactions
Reporting establishment
Report identification
Confirmation date (year/month/day)
Date of serious adverse reaction (year/month/day)
Confirmation of serious adverse reaction (Yes/No)
Imputability level (NA, 0-3)
Change of type of serious adverse reaction (Yes/No)
If Yes, specify
Clinical outcome (if known)
—
Complete recovery
—
Minor sequelae
—
Serious sequelae
—
Death
PART D
Annual notification format for serious adverse reactions
Reporting establishment
Reporting period
This Table refers to
[ ] Whole blood
[ ] Red blood cells
[ ] Platelets
[ ] Plasma
[ ] Other
(use separate table for each component)
Number of units issued (total number of units issued with a given number of blood components)
Number of recipients transfused (total number of recipients transfused with a given number of blood components) (if available)
Number of units transfused (the total number of blood components (units) transfused over the reporting period) (if available)
Total number reported
Number of serious adverse reactions with imputability level 0 to 3 after confirmation (see Annex IIA)
Number of deaths
not assessable
Level
0
Level
1
Level
2
Level
3
Immunological Haemolysis
Due to ABO incompatibility
Total
Deaths
Due to other allo-antibody
Total
Deaths
Non-immunological haemolysis
Total
Deaths
Transfusion-transmitted bacterial infection
Total
Deaths
Anaphylaxis/hypersensitivity
Total
Deaths
Transfusion related acute lung injury
Total
Deaths
Transfusion-transmitted viral Infection
HBV
Total
Deaths
HCV
Total
Deaths
HIV-1/2
Total
Deaths
Other (specify)
Total
Deaths
Transfusion-transmitted parasitical infection
Malaria
Total
Deaths
Other (specify)
Total
Deaths
Post-transfusion purpura
Total
Deaths
Graft versus host disease
Total
Deaths
Other serious reactions (specify)
Total
Deaths