Standards › Standard 5 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · BLD-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 5.2
At a glance
- Test every donation for the infections and blood group with validated tests.
- Record each result before the unit is released.
- Discard any unit with a positive or invalid result.
- Notify the donor and the clinician of a positive result as the policy sets.
- Stop and get help straight away if: a unit is released before all tests are recorded, or a positive unit is not discarded.
1. Purpose
To make sure each donation is tested, and that unsafe units never reach a patient (5.2).
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
Each donation carries a risk of infections that can pass to a patient. Testing every donation with validated tests, and discarding unsafe ones, keeps those infections out of the blood supply.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Laboratory scientist | Runs the tests and checks the results | Scientist |
| Blood bank director | Authorises release and disposal | Clinician |
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. Test.
- Run the validated tests for each donation and record the results (BLD-REG-001).
Key point: Validated tests only.
Step 2. Release.
- Release a unit only when every test result is recorded and valid.
Key point: No result, no release.
Step 3. Discard.
- Discard any positive or invalid unit, and record the disposal.
Key point: Unsafe is discarded, always recorded.
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 |
|---|---|---|---|---|
| Units released with all results recorded | 100% | Monthly | Blood bank director | Escalate to governing body |
| Unsafe units discarded and 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-REG-001 | Donation testing and release register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO guidance on screening donated blood for transfusion-transmissible infections (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)