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Worcestershire Key Documents
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Blood Transfusion Key Document Page

Please note that the clinical key documents are not designed to be printed, but to be viewed on-line.  This is to ensure that the correct and most up to date version is being used.  If, in exceptional circumstances, you need to print a copy, please note that the information will only be valid for 24 hours and should be read in conjunction with the Key Document Supporting Information and/or Key Document intranet page, which will provide additional information including approval and review dates.

Approved by Clinical Governance

Blood Transfusion Policy

The policy details key messages relating to all stages of the transfusion process. 

The Trusts must provide patients with accessible, authoritative and comprehensive information about transfusion therapy and its intended benefits, risks and any available transfusion alternatives. All patients must give informed verbal consent to transfusion where possible. 

The prescription of blood and blood components must be based on a full clinical evaluation of the patient and follow recognised national guidelines.

Safe transfusion phlebotomy practise involves following the Positive Patient Identification procedure and hand labelling samples at the patient’s side.

The collection of blood and blood components must only be done by staff that are competency assessed in this process. This is to ensure they understand the correct checking procedures and transport options available.

The administration of the blood is a critical step. Positive Patient Identification is essential to ensure the correct patient receives the correct blood and/or blood component. The patient must be monitored appropriately to ensure they do not come to harm as a result of the transfusion.

The trust has a legal responsibility to document the final fate (destination) of each unit of blood and blood component we receive, it is essential that the transfusion is documented correctly in the patient records (Blood Safety & Quality Regulations 2005)

Procedure for Sample collection and blood transfusion requests

The process of taking a sample for blood group and antibody screening is given in this procedure.

There are 3 key components to taking samples for transfusion, these are; Patient identification, documentation and communication.

Appropriate identification of the patient is an essential part of delivering a safe transfusion. All patients requiring a transfusion sample must wear an ID band with the 4 key identifiers present (first name, surname, and date of birth and NHS number).

Samples must never be prelabelled. They must always be labelled by hand, at the patient’s side immediately post venepuncture.

This procedure applies to all patients who may require a blood transfusion and covers all specialities.

 Procedure pathway for the Blood collection and transfer to Satellite fridges

This document details the process of blood, blood component and product collection, transfer and return.

The process must be adhered to in order to maintain the integrity of the units and maintain compliance with the Blood Safety & Quality Regulations 2005.

Procedure for the administration of blood components and management of transfusion reactions

This procedure details the preparation required for the administration of a transfusion of blood/blood products to an individual who has been identified as requiring them.

This includes correctly identifying the patient and confirming that administration documentation is accurate, legible and complete. It also involves explaining the process to the patient and confirming patent venous access.

The procedure involves supporting and monitoring the patient throughout the transfusion procedure, identifying and responding promptly to indications of adverse reactions, completing relevant documentation and disposing of used blood bags and other used equipment of completion.

This procedure is relevant to anyone required to carry out this activity to support safer blood transfusion by ensuring the correct blood component or product is given to the correct patient.

Major haemorrhage protocol

The aim of this protocol is to provide a clear management structure for massive blood loss to enable the provision of blood/blood components to be available as quickly as possible as required.

Patients covered:

All patients (except obstetrics) experiencing blood loss as defined by:

  • 50% blood volume loss within three hours
  • a rate of loss of 150 ml/min
  • Or the loss of one blood volume within a 24 hour period.


Staff competencies:

All staff involved in the process of transfusion must have undertaken mandatory training and competency assessment relevant to their role

Management of patients who refuse blood transfusion

There are patients who refuse blood transfusion on religious or other grounds.The most common and well known group of such patients are Jehovah’s witnesses (JW).

Emergency Management of Red Cell and Platelet Shortages

The Chief Medical Officers National Blood Transfusion Committee sub group have stated that a policy should be in place to manage clinical situations during times of Red Cell and Platelet shortages and have introduced a ‘Traffic Light system’ which will be adhered to during such times.

Key Document Supporting Information

Owner: Gill Godding 

Approval date - 4th September 2018 

Review date - 4th September 2020 

This is the most current document and should be used until a revised version is in place

Version: 2

Key Document Supporting Information

Key Document Monitoring Tool

Key Document Amendments

Contact Information

Contact Numbers

Transfusion Practitioners

Int 30633

Ext 01905 733317

WRH BLOOD BANK  - 30635

ALEX BLOOD BANK - 42179

Page last updated: 07 February 2019