Standards › Standard 5 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · BLD-SOP-006 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 5.9
At a glance
- Emergency release is authorised only by a named senior clinician.
- The checks still made are written and are done before release.
- The release is recorded for the patient, with the reason.
- Unused units are returned and tested as the procedure sets.
- Stop and get help straight away if: blood is released urgently with no named authoriser or no record for the patient.
1. Purpose
To release blood in an emergency safely, with every decision recorded (5.9).
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 sometimes must be released before every test is complete, because a patient is bleeding. This is safe only when a written procedure names who may authorise it and each release is recorded and reviewed.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Named senior clinician | Authorises the release | Clinician |
| Blood bank technician | Makes the checks still required and records them | 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. Authorise.
- The named senior clinician authorises in writing or by the set route, with the reason (BLD-FRM-004).
Key point: Named, and recorded.
Step 2. Check.
- Make the checks still required, such as group and sample checks, and record them.
Key point: Some checks still happen.
Step 3. Record and return.
- Record the release for the patient, and return and test any unused unit as the procedure sets.
Key point: Every unit is accounted for.
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 |
|---|---|---|---|---|
| Emergency releases with authoriser and reason recorded | 100% | Quarterly | Blood bank director | Escalate to governing body |
| Emergency releases reviewed | 100% | Quarterly | 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-004 | Emergency release record | Record |
| MED-01 | Medical emergency protocol development | Course |
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)