Standards › Standard S1 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HOS-SOP-008 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criterion S1.8
At a glance
- Check the patient identity against the blood product at the bedside, by two staff.
- Start the transfusion within the time set after the blood is issued.
- Watch for and record any reaction, and report it at once.
- Keep the blood cold until use, and log the temperature.
- Stop and get help straight away if: a transfusion is started without a two-person identity check.
1. Purpose
To make sure every transfusion goes to the right patient, is monitored, and that reactions are caught and reported (S1.8). Based on the WHO clinical use of blood guidance.
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Transfusing the wrong blood is one of the most dangerous errors in hospital. Two staff check the patient and the product at the bedside.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Two checking staff | Check identity together at the bedside | Trained in transfusion |
| Transfusion lead | Owns the procedure and reviews reactions | Senior clinician |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Bedside check form (HOS-FRM-007) | Current | Attached to the blood bag |
| Blood storage temperature log | Current | Read each day |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Verify.
- Two staff check the patient’s name, number and date of birth against the bag label and the request.
- Both sign.
Key point: Two checks, at the bedside.
Step 2. Start.
- Start within the time set.
- Stay with the patient for the first 15 minutes.
Key point: Most reactions start early.
Step 3. Monitor.
- Check vital signs at the set times during the transfusion.
Key point: Watch, record, respond.
Step 4. React.
- If a reaction is suspected, stop the transfusion, keep the line open, and call the senior clinician.
- Report the reaction the same day.
Key point: Stop first, then decide.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Transfusions with two-person check recorded | 100% | Monthly | Transfusion lead | Escalate to chief executive |
| Reactions reported the same day | 100% | Monthly | Transfusion lead | Escalate to clinical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| HOS-FRM-007 | Bedside transfusion check and reaction record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | WHO guidance on the clinical use of blood (developing a national policy and guidelines). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)