Standards › Standard 5 › Policies
Policy · BLD-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 5.5
At a glance
- Blood is issued only against a valid, signed request.
- The patient’s identity and the request are checked before issue.
- Compatibility is checked and recorded before issue.
- Every issue is recorded with its time and the person who received it.
- Stop and get help straight away if: blood is issued with no valid request, or to a patient whose identity has not been checked.
1. Purpose
To make sure blood goes only to the right patient, against a valid request (5.5).
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 given to the wrong patient can kill. A valid request, a compatibility check and a recorded issue make the chain of checks visible at each step.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Blood bank director | Owns the issue rule | Clinician |
| Blood bank technician | Checks request and issues | 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. Request.
- Check the request is valid, signed and has the patient’s identity (BLD-FRM-002).
Key point: No request, no issue.
Step 2. Compatibility.
- Complete the compatibility check and record it before issue.
Key point: Checked before issue.
Step 3. Issue.
- Issue the unit, record the time and the person who received it, and check the bedside check at the ward (HOS-FRM-007).
Key point: Two checks, two records.
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 |
|---|---|---|---|---|
| Issues against a valid request | 100% | Monthly | Blood bank director | Escalate to governing body |
| Issues with compatibility recorded | 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 |
|---|---|---|
| BLD-FRM-002 | Blood request and issue record | Record |
| HOS-SOP-008 | Blood transfusion | Procedure |
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 |
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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)