Standards › Standard 5 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · BLD-SOP-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 5.4
At a glance
- Blood and products are stored within the set temperature range.
- The temperature is monitored continuously, and recorded at least twice a day.
- Transport uses validated containers that keep the range.
- Any out-of-range reading is actioned and the unit is quarantined.
- Stop and get help straight away if: a unit is issued after being out of range, or a fridge alarm is not answered.
1. Purpose
To keep blood safe from the donor to the patient, with the cold chain monitored (5.4).
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
Blood spoils if it is too warm or too cold, and no one may notice until it is given. Continuous temperature monitoring, with a set response to any failure, keeps products safe in storage and on the road.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Blood bank director | Owns the cold chain and the back-up plan | Clinician |
| Blood bank technician | Monitors and records the temperature | Technician |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
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. Store.
- Keep each product in the set range and in the set place.
- Check the alarm works each day.
Key point: Range and place are fixed.
Step 2. Record.
- Record the temperature at least twice a day on PHM-FRM-001, and at once after any alarm.
Key point: Recorded, not assumed.
Step 3. Transport.
- Use the validated container, and record the temperature at handover.
Key point: The chain holds on the road.
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 |
|---|---|---|---|---|
| Temperature readings in range | 100% | Monthly | Blood bank director | Escalate to governing body |
| Alarms answered within the set time | 100% | Monthly | Blood bank director | Escalate to governing body |
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 |
|---|---|---|
| PHM-FRM-001 | Fridge temperature log | Log |
| BLD-REG-002 | Donation traceability register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the Council of Europe Guide to the Preparation, Use and Quality Assurance of Blood Components. |
| 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 |
E-learning for this document
No e-learning course is linked to this document yet.
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)