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Supporting Guidance Standard 2.8

Health Services in Wales

Supporting Guidance
Standard 2.8: Blood Management


What is the Standard about?

To ensure that people have timely access to a safe and sufficient supply of blood, blood products and blood components when needed.


Who is it for?

All organisations where blood, blood products and components are produced, used and managed.

In relation to the standard criteria below (in bold) the following key questions need to be considered:

Health services have robust governance systems in place to maintain a safe sufficient supply of blood, blood components and blood products to support timely appropriate and effective use for all.

  • Are your governance systems robust enough to identify potential risks and appropriate actions to ensure the safe sufficient supply of blood, blood components and blood products?

There is compliance with legislation and national guidance on the supply and appropriate use of blood, blood components and products.

  • How do you ensure the minimum, appropriate use of blood, components and products?
  • What systems do you have in place to promote the use of alternatives and adjuncts to blood transfusion?
  • How do you audit compliance with legislation and national guidance?
  • How do you act on any non compliance identified?
  • How are you assured that you have an adequate supply?
  • How do you monitor the safe and appropriate use of blood, components, and products?

Effective schemes and systems are in place to actively manage stock, minimise wastage, and plan effectively for shortages.

  • How do you monitor waste?
  • How do you minimise waste?
  • What are your ‘cold chain’ arrangements?
  • What arrangements are in place for effective stock rotation and management of supply?
  • How do you plan for shortages and communicate change internally and externally?

A continuous innovative programme of education, training and competence assessment covers all staff involved in the transfusion process in line with national strategy.

  • How do you ensure staff are up to date with policies and procedures?
  • How do you provide education and training?
  • How do you assess competence?

Processes are in place that enhance the safety of blood transfusion and support the recognition and reporting of, and shared learning from all incidents, adverse blood events and reactions.

  • How do you ensure that patient identification and blood component checks are established at all stages of the transfusion process?
  • What arrangements do you have for documenting all near misses, complaints, incidents, serious adverse reactions and serious adverse events to the MHRA (via SABRE)?
  • What arrangements do you have for reporting events internally and to external bodies e.g. Serious Hazards of Transfusion (SHOT), Welsh Government?
  • How do you ensure robust investigation, implement corrective and preventative actions and share learning

There is a collaborative approach to optimal blood management

  • How do you ensure effective partnership working between organisations?
  • How do you ensure that patients/donors/clinicians collaborate in the delivery of care?
  • How do you ensure that relevant, timely information is available to all, so as to inform choice and support shared decision making?
  • How do you demonstrate that resources are used efficiently, prudent healthcare principles are applied and interventions deliver the intended outcome?