Governance principles

The National Safety and Quality Health Service (NSQHS) standards provide a clear statement about the level of care consumers can expect from health services.

Incorporated within the standards is The Blood Management Standard.

The intention of the Blood Management Standard is to "improve outcomes for patients by identifying risks, and using strategies that optimise and conserve a patient's own blood, as well as ensuring that any blood and blood products that patients recieve are safe and appropriate".

A quality management system is needed in all situations where blood component therapy is given and to support clinicians in patient blood management.

Quality in the clinical use of blood components implies administering the right amount of the right component in the right way to the right patient at the right time. It also includes adequate documentation of both the transfusion process and outcomes.

All institutions that transfuse blood products should implement national and local policies and written procedures for:

• Preoperative anaemia and iron deficiency assessment and management pathways, or evidence through chart audit of a haemoglobin assessment
• Identification of patients at high risk of bleeding
• Use of appropriate diagnostic assays to assess cause of bleeding in a timely manner
• Use of decision support tools to support decision-making about bleeding management
• Cell salvage procedures (an autologous blood conservation technique for minimising blood loss)
• Use of all treatment options
• Management strategies that help minimise the likelihood of transfusion (including any PBM program)
• Support for transfusion alternatives and blood product refusal
• Pre-transfusion practice – strategies to optimise and conserve the patient’s own blood, identify patients at risk of bleeding, and pre-transfusion blood sampling and testing
• Pre-, intra- and post-treatment or intervention assessment and documentation of a patient’s haemoglobin, ferritin and iron studies
• Prescribing practice and clinical use of blood and blood products, and decisions to use blood and blood products, including any specific requirements (for example, irradiated products)
• Record taking and reporting, including completion of local blood request forms
• Administration of blood and blood products, including venous access; the use of equipment, concurrent fluids and medications; pre-administration identity check of patient and blood product; infusion rates; and observations and monitoring1
• Identity checks at the time of pre-transfusion specimen collection, testing, product allocation, and collection of blood products from storage
• Management of blood and blood products – including receipt, storage, collection and transport, wastage, and contingency planning
• Informed patient consent relating to blood and blood products, and partnering with patients in their own care. 

Policies, procedures and protocols should accord with national evidence-based guidelines. Where there are no national evidence-based guidelines, develop a local policy, procedure or protocol that communicates the appropriate practices, or rely on clinical judgement. 

What are the responsibilities?

The prescriber is responsible for ensuring that blood component therapy is only given when the benefits of the transfusion outweigh the risks and that the patient is appropriately monitored during the transfusion procedure.

There is an organisational responsibility to ensure that use of blood is monitored and reviewed, and that actions are taken to ensure that blood is used safely and appropriately.

There should be a clinical management group (e.g. a Blood Management Committee) who reports to the hospital executive. This group is responsible for:

• reviewing transfusion policies and procedures
• reviewing the arrangements for training and continuing education of staff in transfusion policies and procedures
• reviewing adverse transfusion events, including near misses (e.g. identified clerical errors)
• reviewing the appropriateness of blood transfusion and making recommendations about the proper use of blood components and fractionated products, and
• recommending corrective action in transfusion practice.

Updated January 2026