Standards › Standard 5 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · BLD-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 5.1
At a glance
- Each donor is screened by the written questionnaire and the examination before donation.
- A donor who does not meet the criteria is deferred.
- Every deferral is recorded with its reason and the time to return.
- Donors are told in a way they understand.
- Stop and get help straight away if: a donation is taken from a donor who has not been screened, or a deferral is not recorded.
1. Purpose
To make sure only suitable donors give blood, and that every decision is recorded (5.1).
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
A donor with an infection or a condition that makes donation unsafe can put a recipient at risk. Screening before every donation, and recording each deferral, is the first barrier.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Donor clinician | Screens each donor and decides on deferral | Clinician |
| Donor nurse | Records the screening and the deferral | Nurse |
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. Screen.
- Complete the donor questionnaire and examination before each donation (BLD-FRM-001).
Key point: Every donation, every donor.
Step 2. Decide.
- Defer any donor who does not meet the criteria, and record the reason and the return date.
Key point: Deferral is a safety decision.
Step 3. Tell.
- Explain the deferral to the donor in a language they understand, and offer advice where needed.
Key point: The donor understands.
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 |
|---|---|---|---|---|
| Donations with completed screening | 100% | Monthly | Blood bank director | Escalate to governing body |
| Deferrals with reason 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-001 | Donor screening and deferral record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Donor criteria to follow the national blood service guidance. Based on the WHO framework for voluntary blood donation (2010). |
| 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)