STANDARD OPERATING

PROCEDURE

BLOOD BANKING
 Table of Contents
SOP # PAGE

1 Acceptance of Blood/Blood Products…………………………………… 1-3

2 Management of Non-conforming Blood/Blood Product…………….. 4-5
3 Compatibility Testing Request Form………………………………….. 6-8
4 Collection and Labelling of Blood Sample…………………………….. 9 - 11
5 Validity and Retention of Blood Sample………………………………. 12 - 13
6 Compatibility Testing………..…………………………………………… 14 - 24
7 Blood Grouping Discrepancies…………………………………………. 25 - 28
8 Incompatible Results…………………………………………………….. 29 - 30
9 Issuance of Blood/Blood Product………………………………………. 31 - 33
10 Return of consumed Blood/Blood Product……………………………. 34 - 35
11 Return of unused Blood/Blood Product……………………………….. 36 - 37
12 Return of Incompatible Blood/Blood Product…………………………. 38 - 39
13 Reassignment of Blood/Blood Product………………………………… 40 - 41
14 Blood Transfusion Reaction…………………………………………….. 42 - 45
15 Blood Pool Usage………………………………………………………… 46 - 47
16 First to expire first out scheme………………………………………….. 48 – 49
 SOP
01
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 1 of 3
Date of Next
Subject : ACCEPTANCE OF Review
BLOOD/BLOOD PRODUCTS Prepared by A.N.B

1.0 PURPOSE: To make certain that scheme in receiving blood/blood product is in accordance w
with the Blood Banking Standards.
2.0 SCOPE: This covers to all Laboratory Staff and Nurses taking part in the endorsement
and receipt of blood/blood products for deposit.
3.0 PROCEDURE:
 SOP
01
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 2 of 3
Date of Next
Subject : ACCEPTANCE OF Review
BLOOD/BLOOD PRODUCTS Prepared by A.N.B

DETAILED INSTRUCTIONS:

1.0 Receipt of blood/blood product in its container

1.1 Med. Tech. checks the presence of ice. It should not be in direct contact with the blood unit/s.
2.0 Verification of documents
2.1 Med. Tech. Verifies TRANSMITTAL FORM from the issuing Blood Bank Facility. It must
contain the following information.
2.1.1 Name of the Patient
2.1.2 Blood Group
2.1.3 Blood Component
2.1.4 Serial Number
2.1.5 Expiry Date
2.1.6 Number of Units
2.1.7 Name of Issuing Facility
2.1.8 Name and Signature of Issuing Personnel
2.1.9 Date and Time of Issuance of Blood Product
2.1.10 Name and Signature of the Recipient
3.0 Assessment of blood/blood product with the standard
3.1 Med.Tech. assesses the conformity of blood product. Scrutinize its appearance and condition.
3.1.1 In cases of non-conformity refer to SOP on Management of non-conforming
blood/blood product. Criteria for the non-conformity of blood product:
3.1.1.1 Presence of Hemolysis
3.1.1.2 Clots in the blood product
3.1.1.3 Damaged or leaked blood bag
3.1.1.4 Inadequate length and segment of blood donor tubing at least 3 segments
3.1.1.5 Incorrect label
3.1.1.6 Incorrect blood type/component as requested
3.1.2 If it conforms, proceed to the next procedure.
 SOP
01
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 3 of 3
Date of Next
Subject : ACCEPTANCE OF Review
BLOOD/BLOOD PRODUCTS Prepared by A.N.B

4.0 Documentation
Med. Tech. records pertinent information on the logbook as proof of deposit:
4.1 Date and time of receipt
4.2 Patient’s information:
A. Name
B. Age
C. Sex
4.3 Blood Group of the patient and donor
4.4 Source of Blood Product
4.5 Blood component
4.6 Serial number and expiration date of the Blood Product
4.7 Name and signature of the Nurse endorsing the Blood Product and receiving
laboratory staff.
5.0 Storage
Store the blood/blood product accordingly:
Product Storage Life Storage Temperature
Whole Blood and PRBC 35 Days 2◦C
Platelet Concentrate 5 Days 20◦C to 24◦C
Fresh Frozen Plasma (FFP) 1 year -30◦C or colder
6 months -25◦C
3 months -21 to -24◦C
Cryoprecipitate Same as FFP
Washed RBC 24 hours 2 to 6◦C
Any Product with OPEN SYSTEM 24 ours

6.0 Materials required:

6.1 Equipment-
6.1.1 Blood Bank
6.2 Miscellaneous
6.2.1 Ice chest/box with ice
6.2.2 Registry logbook
6.2.3 Transmittal form
 SOP
02
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 1 of 2
Date of Next
Subject : MANAGEMENT OF NON- Review
CONFORMING BLOOD/BLOOD Prepared by
A.N.B
PRODUCT

1.0 PURPOSE: To ensure that non-conforming blood/blood product will be handled accordingly.
2.0 SCOPE: This covers to all Laboratory Staff and Nurses taking part in the endorsement
and receipt of blood/blood products for deposit.
3.0 PROCEDURE:
 SOP
02
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 2 of 2
Date of Next
Subject : MANAGEMENT OF NON- Review
CONFORMING BLOOD/BLOOD Prepared by
A.N.B
PRODUCT

DETAILED INSTRUCTIONS:

1.0 Categorization of non-conformity

1.1 Med. Tech. categorizes the criteria of a non-conforming blood/blood product:
1.1.1 Presence of Hemolysis
1.1.2 Clots in the blood product
1.1.3 Damaged or leaked blood bag
1.1.4 Inadequate length and segment of blood donor tubing (at least 3 segments)
1.1.5 Incorrect and/or unclear label
1.1.6 Incorrect blood type/component as requested
2.0 Inform Nurse-on-duty
2.1 Med. Tech. informs immediately the endorsing nurse on the non-conformance of the
blood/blood product.
3.0 Inform patient/patient’s watcher
3.1 Nurse-on-duty calls the attention of the patient/patient’s watcher for immediate return of
the blood/blood product to the issuing blood bank facility.
4.0 Preparation of blood/blood product
4.1 The Med. Tech./Lab Aide prepares and place the blood/ blood product in its
recommended container with ice and seal it properly.
5.0 Instructions
5.1 Med Tech. gives instructions to the client on the proper handling of blood/blood products.
6.0 Documentation
6.1 Med.Tech. accomplishes transmittal from for the return of blood/blood product to the
issuing facility and records it.
7.0 Materials required
7.1 Pack of ice
7.2 Recommended container for blood/blood product
7.3 Transmittal form
 SOP
03
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 1 of 3
Date of Next
Subject : COMPATIBILITY TESTING Review
REQUEST FORM Prepared by A.N.B

1.0 PURPOSE: To ensure the correct information and identity of the patient before performing
phlebotomy procedure.
2.0 SCOPE: This covers to all Laboratory Staff and Nurses involved in the requisition
and accomplishment of the request form.
3.0 PROCEDURE:
 SOP
03
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 2 of 3
Date of Next
Subject : COMPATIBILITY TESTING Review
REQUEST FORM Prepared by A.N.B

DETAILED INSTRUCTIONS:

1.0 Receipt and verification of compatibility testing request form

1.1 Med. Tech. checks the accuracy of information on the
COMPATIBILITY TESTING REQUEST FORM:

1.1.1 Patients complete name including name extension

1.1.2 Age
1.1.3 Sex
1.1.4 Date of Birth
1.1.5 Patient’s blood
1.1.6 Room number
1.1.7 Hospital case number
1.1.8 Clinical diagnosis
1.1.9 Attending physician
1.1.10 Type of request
A. Routine
B. STAT
1.1.11 Indication
1.1.12 History of previous transfusion
1.1.13 Type of Crossmatching
A. Phases
B. Saline Phase only
C. Type specific only, No Crossmatching
D. Group O Blood, No Crossmatching
1.1.14 Name and signature of the Requesting Physician
1.1.15 Name and signature of the person carrying out the request form
2.0 Assessment for acceptability
2.1 If request is acceptable, proceed to SOP #3.
2.2 If the request is not acceptable, inform the Nurse-on-duty for the submission of a new
request.
 SOP
03
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 3 of 3
Date of Next
Subject : COMPATIBILITY TESTING Review
REQUEST FORM Prepared by A.N.B

3.0 Documentation
3.1 Nurse-on-duty records the endorsement on the laboratory receiving logbook.
4.0 Materials required:
4.1 Receiving logbook
4.2 Compatibility testing request form
 SOP
04
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 1 of 3
Date of Next
Subject : COLLECTION and LABELING Review
OF BLOOD SAMPLE FOR Prepared by
A.N.B
COMPATIBILITY TESTING

1.0 PURPOSE: To guarantee the exact identity of the patient and collection of the right blood sample
needed for an accurate compatibility testing procedure.
2.0 SCOPE: This concerns all laboratory staff who are responsible in the collection of blood sample.
It also covers nurses and patient’s watchers with personal access in identifying the
patient.
3.0 PROCEDURE:
 SOP
04
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 2 of 3
Date of Next
Subject : COLLECTION and LABELING Review
OF BLOOD SAMPLE FOR Prepared by
A.N.B
COMPATIBILITY TESTING

DETAILED INSTRUCTIONS:

1.0 Pre-collection procedure

1.1 Upon receipt of compatibility requisition form, the phlebotomist prepares the necessary
materials for venipuncture and proceeds to the ward.
2.0 Identification of the patient in the ward
2.1 Med. Tech. asks over the patient to identify his/herself by family name, given name and
middle name.
2.2 For incoherent and unconscious patient, ask for a co-identifier (NOD and/or patient’s
watcher) to be certain of his/her identity.
3.0 Confirmation of patient’s identity
3.1 Med. Tech./phlebotomist checks for any discrepancy between the identity of the patient
and the requisition form. Compare data on the patient’s request form with the established
identification of the patient.
3.1.1 If none, the phlebotomist collects blood sample
3.1.2 If there is any discrepancy:
3.1.2.1 Inform Nurse-on-duty
3.1.2.2 Nurse-on-duty re-establishes patient’s identification and endorses
corrected compatibility testing form.
4.0 Collection of blood sample
4.1 Med. Tech./phlebotomist performs the collection of blood sample.
4.1.1 Select a suitable site for venipuncture.
4.1.2 Perform the venipuncture.
4.1.3 Collect the sample in the appropriate container.

Test Type Evacuated Tube Volume of Sample

1. Blood Grouping EDTA Tube 0.5ml and 2ml

2. Compatibility testing EDTA Tube 2ml

3. Coombs test EDTA Tube 2ml

 SOP
04
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 3 of 3
Date of Next
Subject : COLLECTION and LABELING Review
OF BLOOD SAMPLE FOR Prepared by
A.N.B
COMPATIBILITY TESTING

5.0 Sample tubes labelling

5.1 After the collection, the Med. Tech/phlebotomist labels the collection tubes at the bedside
or drawing area.
5.1.1 Complete Name of the Patient
5.1.2 Age and Gender
5.1.3 Date of collection
6.0 Submission of Blood Sample
6.1 Med. Tech/phlebotomist submits sample and the Compatibility request form to the Blood
Bank the soonest possible time.
7.0 Materials required:
7.1 Lavender top test tube
7.2 Syringe with needle
7.3 Tourniquet
7.4 Cotton with and without alcohol
7.5 Writing pen/marker
7.6 Request form
 SOP
05
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 1 of 2
Date of Next
Subject : VALIDITY AND RETENTION OF Review
BLOOD SAMPLE Prepared by A.N.B

1.0 PURPOSE: To evaluate the criteria of a good sample for compatibility testing.
2.0 SCOPE: This covers all laboratory staff engaged in the collection and performance of the
compatibility testing.
3.0 PROCEDURE:
 SOP
05
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 2 of 2
Date of Next
Subject : VALIDITY AND RETENTION OF Review
BLOOD SAMPLE Prepared by A.N.B

DETAILED INSTRUCTIONS:
1.0 Receipt or required document and sample
1.1 Med. Tech. verifies the patient information on the compatibility requisition form and the
sample tube.
1.2 For any discrepancy,

Nature of Discrepancy Action Recommendation

Documents Inform Nurse-on-duty Retain discrepant document
and prepare new request
Sample Inform Nurse-on-duty and Repeat sample collection and
Phlebotomist Retain the discrepant sample

2.0 Assess the condition of a quality sample

Med. Tech. assesses the following:
I. Patient sample
2.1 Properly labelled
2.1.1 Complete name of the patient
2.1.2 Date of collection
2.2 Sufficient volume, not less than 500 uL collected EDTA tube
2.3 Correct sample tube as specified
2.4 No hemolysis
II. Donor sample
2.5 Select segment that is not clotted.
3.0 Storage/retention of sample

Temperature 18◦C - 25◦C 4◦C -30◦C

EDTA whole blood Up to 48 hours Up to 7 days N/A
Separated Plasma/serum N/A Up to 7 days 6 months

3.1 Retain segment of blood donor for 7 days after blood transfusion.
 SOP
06
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 1 of 11
Date of Next
Subject : COMPATIBILITY TESTING Review
Prepared by A.N.B

1.0 PURPOSE: To detect unexpected blood group antibodies in patients serum/plasma against antigen
on donor cells and ensure the safety of the patent during the blood transfusion.
2.0 SCOPE: This covers all laboratory staff performing compatibility testing.
3.0 PROCEDURE:
 SOP
06
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 2 of 11
Date of Next
Subject : COMPATIBILITY TESTING Review
Prepared by A.N.B
 SOP
06
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 3 of 11
Date of Next
Subject : COMPATIBILITY TESTING Review
Prepared by A.N.B

DETAILED INSTRUCTIONS:

1.0 Compatibility Testing Worksheet

1.1 Med. Tech. accomplishes Compatibility testing worksheet with the following information:
1.1.1 Complete name of patient
1.1.2 Age and gender
1.1.3 Birth date
1.1.4 Blood group of patient/donor
1.1.5 Room number
1.1.6 Serial number of blood unit
1.1.7 Source and component
1.1.8 Expiry date
1.1.9 Hospital case number
1.1.10 Date and time compatibility testing started and ended
2.0 Segment from blood bag for compatibility testing
2.1 Select segment form the donor tubing for compatibility testing
3.0 Return blood units to appropriate storage
3.1 Return the blood bag to its proper storage after getting segment for testing
4.0 Prepare Red Cell Suspension – patient and donor
4.1 Preparation of pooled 3% Known cell suspension (Known A and Known B)
4.1.1 Collect 3-5 segments from different donor units of Blood type A and B
4.1.2 Label tube as KAC for known A cells and deliver red cells from 3-5 segments
prepared.
4.1.3 Label tube as KBC for known B cells and deliver red cell from 3-5 segments
prepared.
4.1.4 Add ¾ full buffered saline solution (BSS) to both tubes (wash)
4.1.5 Cover with parafilm and invert 3 to 4 times
4.1.6 Spin at 3000 rpm for 2-3 minutes
4.1.7 Decant supernatant
4.1.8 Repeat washing procedure twice
4.1.9 The remaining red cell is considered as the Pooled Packed cell.
 SOP
06
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 4 of 11
Date of Next
Subject : COMPATIBILITY TESTING Review
Prepared by A.N.B

4.2 Preparation of 3% red cell suspension

4.2.1 Transfer 50 uL to 100 uL of whole blood or packed red cells to a test tube.
4.2.2 Wash the cells 3 times with buffered normal saline.
4.2.3 Completely remove the saline on the last washing.
4.2.4 Transfer 30uL of washed packed red cells to a test tube containing 1 mL
buffered normal saline.
4.2.5 Mix or cover the tube with parafilm and invert gently.

5.0 Perform ABO and Rh blood grouping

5.1 Forward grouping
5.1.1 Prepare patient cell suspension (refer to SOP of Preparation of Red Cell
Suspension)
5.1.2 Label tubes A, B, D respectively.
5.1.3 Add 1 drop of Anti-A typing sera to tube A
5.1.4 Add 1 drop of Anti-A typing sera to tube B
5.1.5 Add 1 drop of Anti-A typing sera to tube D
5.1.6 Pipette 50uL or 1 drop of patients or donor cell suspension to tubes A, B, D
5.1.7 Mix each tube gently
5.1.8 Centrifuge all tubes for 10 seconds at 3000 rpm.
5.1.9 Gently dislodge red cell button
5.1.10 Check for agglutination

Interpretation of results:
Blood group Anti-A sera Anti-B sera

Type A Agglutination No Agglutination

Type B No Agglutination Agglutination

Type O No Agglutination No Agglutination

Type AB Agglutination Agglutination

 SOP
06
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 5 of 11
Date of Next
Subject : COMPATIBILITY TESTING Review
Prepared by A.N.B

Grade results (refer to Agglutination Grading Table)

Macroscopically observed findings Designation

4+
One solid agglutinate
3+
Several large agglutinates
2+
Medium-size agglutinates, clear background
1+
Small agglutinates turbid background
1=
Very small agglutinates, turbid background
W+ or +/-
Barely visible agglutination, turbid background
0
No agglutination
Mf
Mixture of agglutinated and unagglutinated red cells (mixed field)
H
Complete Hemolysis
PH
Partial Hemolysis

Record results in the worksheet.

5.2 Reverse grouping
5.2.1 Label test tubes known A and known B respectively.
5.2.2 Deliver 2 drops patient or donor’s plasma into each tube.
5.2.3 To known A test tube, add 1 drop of known A cells.
5.2.4 To known B test tube, add 1 drop of known B cells.
5.2.5 Mix and centrifuge for 10 seconds at 3000 rpm.
5.2.6 Gently dislodge red cell button
5.2.7 Check for agglutination
 SOP
06
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 6 of 11
Date of Next
Subject : COMPATIBILITY TESTING Review
Prepared by A.N.B

Interpretation of results:
Blood group Known A cells Known B cells

Type A No agglutination Agglutination

Type B Agglutination No agglutination
Type O Agglutination Agglutination
Type AB No agglutination No agglutination

Grade results (refer to Agglutination Grading Table)

Macroscopically observed findings Designation

One solid agglutinate 4+

Several large agglutinates 3+
Medium-size agglutinates, clear background 2+
Small agglutinates turbid background 1+
Very small agglutinates, turbid background 1=
Barely visible agglutination, turbid background W+ or +/-
No agglutination 0
Mixture of agglutinated and unagglutinated red cells (mixed field) Mf
Complete Hemolysis H
Partial Hemolysis PH

6.0 Assessment of ABO grouping

6.1 If result is discrepant, perform SOP no.
6.2 If it has no discrepant, proceed to the next step.
 SOP
06
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 7 of 11
Date of Next
Subject : COMPATIBILITY TESTING Review
Prepared by A.N.B

7.0 Perform crossmatching

Gel Method
7.1 Prior to the initial phase of the compatibility test procedure, perform Forward and
Reverse ABO Blood Grouping and Rh Blood Grouping for patient and donor units.
(Refer to SOP for Blood Grouping)
7.2 Label LISS/Coombs cards with patients name and serial number of donor units.
7.3 Pipette 50uL of the donor red cell suspension to the micogel tube.
7.4 Add 25uL of the patients’ plasma /serum to each micro tube.
7.5 Incubate the ID card for 15 minutes at 37 ◦C in the ID-Incubator
7.6 Centrifuge the ID-card for 10 minutes in the ID-Centrifuge.
7.7 Read and grade results.
7.8 Refer to chart on interpretation of result.

INTERPRETATION OF RESULTS

Negative/Compatible: Compact button of cells on the bottom of the microgel tubes.

Positive/Not compatible: Agglutinated cells forming a red line on the surface of the gel

Agglutinates dispersed in the gel

REACTION GRADING of GEL TECHNOLOGY

RESULT INTERPRETATION
COMPATIBLE All cells pass through the gel media and form a cell button at
the bottom of the microtubes
INCOMPATIBLE (1+) Agglutinated cells disperse throughout the gel media and may
concentrate toward the button of the microtubes
Agglutinated cells disperse into gel media and are observed
INCOMPATIBLE (2+) throughout the length of the microtubes
INCOMPATIBLE (3+) Agglutinated cells begin to disperse into gel media and are
concentrated near the top of the microtubes
INCOMPATIBLE (4+) Agglutinated cells form a cell layer at the top of the gel media
MIXED FIELD Agglutinated cells form a cell layer at the top of the gel media.
Unagglutinated cells pass to the bottom of the microtubes.
 SOP
06
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 8 of 11
Date of Next
Subject : COMPATIBILITY TESTING Review
Prepared by A.N.B

Test Tube Method

I. Immediate Spin
I.1 Label glass tubes for each donor red cell suspension to be tested with patient’s
serum or plasma.
I.2 Add 2 drops serum or plasma to a test tube.
I.3 Add 1 drop of 3-5% red cell suspension to the tube.
I.4 Mix tubes and centrifuge for 10 seconds at 3000 rpm
I.5 Examine tubes for Hemolysis and resuspend the red cell button, check for
agglutination
I.6 Record result.

INTERPRETATION:
POSITIVE result shows agglutination or Hemolysis.
NEGATIVE result shows no agglutination or Hemolysis and indicate a COMPATIBLE
Immediate spin Crossmatch.

 In cases of EMERGENCY, above procedure can be instituted to release a unit of

blood.

II. Thermo Phase

II.1 Add 2 drops of LISS additive mix and incubate at 37◦ for 15 minutes.
II.2 Centrifuge for 10 seconds at 3000 rpm and observe for Hemolysis or
agglutination.
II.3 Grade and record result.

INTERPRETATION:
POSITIVE result shows agglutination or Hemolysis.
NEGATIVE result shows no agglutination or Hemolysis and indicates a COMPATIBLE
Thermo Phase Crossmatch.
 In cases of EMERGENCY, above procedure can be instituted to release a unit of
blood.
 SOP
06
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 9 of 11
Date of Next
Subject : COMPATIBILITY TESTING Review
Prepared by A.N.B

III. Antihuman Globulin

III.1 Fill tubes (3/4 full) with 9% buffered NSS and centrifuge for 2 minutes at 3000
rpm for washing.
III.2 Repeat above procedure 3 more times decanting each time as much buffered
saline.
III.3 Decant tubes in the last wash to a cell button
III.4 Add 2 drops of AHG (Polyspecific or IgG depending on laboratory preference).
Resuspend red cell button.
III.5 Spin tubes for 10 seconds at 3000 rpm.
III.6 Read for agglutination and Hemolysis.

INTERPRETATION:
POSITIVE result shows agglutination or Hemolysis.
NEGATIVE result shows no agglutination or Hemolysis and indicate a COMPATIBLE
Antihuman globulin phase crossmatch.

Agglutination Grading Table

Macroscopically observed findings Designation

One solid agglutinate 4+

Several large agglutinates 3+
Medium-size agglutinates, clear background 2+
Small agglutinates, turbid background 1+
Very small agglutinates, turbid background 1=
Barely visible agglutination, turbid background W+ or +/-
No agglutination 0
Mixture of agglutinated and unagglutinated red cells (mixed field) Mf
Complete Hemolysis H
Partial Hemolysis some red cells remain PH
 SOP
06
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 10 of 11
Date of Next
Subject : COMPATIBILITY TESTING Review
Prepared by A.N.B
8.0 Worksheet documentation
8.1 Document all results on the compatibility worksheet.
8.2 Report result as compatible or incompatible.
8.3 If incompatible, inform Nurse-on-duty
9.0 Verification of results
9.1 All results on the worksheet are verified by a co-Med. Tech. before its final transcription.
10.0Transcription of results
10.1 Prepare official Compatibility Testing Result form with the following information:
10.1.1 Patient’s full name
10.1.2 Age/Sex
10.1.3 Birth date
10.1.4 Room number
10.1.5 Patient’s blood type
10.1.6 Serial number of donor unit
10.1.7 Blood type of the donor unit – reverse and forward typing
10.1.8 Expiry date
10.1.9 Physician
10.1.10 Diagnosis
10.1.11 Type of request
10.1.12 Blood product
10.1.13 Source of blood component
10.1.14 Result of crossmatching result
10.2 Check the information and results transcribed on the compatibility testing result
form with the data on the worksheet.
11.0Labelling of compatible blood units
11.1 Fill up the compatibility label form with the following:
11.1.1 Patient full name
11.1.2 Age/Sex
11.1.3 Birth date
11.1.4 Ward or Room number
11.1.5 Blood type
11.1.6 Serial number
11.1.7 Expiry date
11.1.8 Source
 SOP
06
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 11 of 11
Date of Next
Subject : COMPATIBILITY TESTING Review
Prepared by A.N.B
11.2 Attach compatibility label to the identified blood units and store blood/blood
products accordingly.
12.0Documentation
12.1 Record all results on Blood bank logbook
12.2 Med. Tech performing the compatibility testing procedure must affix her signature
on the blood bank logbook.
13.0Materials required:
13.1 Equipment
13.1.1 Binocular Microscope
13.1.2 Serological centrifuge
13.1.3 Dry bath
13.1.4 Mechanical pipette
13.1.5 Blood bank refrigerator for storage
13.1.6 Timer
13.2 Glassware/other materials
13.2.1 Test tubes
13.2.2 Test tube rack
13.2.3 Glass slide
13.2.4 Calibrated plastic pipettes
13.3 Reagents
13.3.1 ABO typing sera
13.3.2 Anti-D sera
13.3.3 Low ionic strength saline solution
13.3.4 Buffered normal saline solution
13.3.5 Antihuman globulin
13.3.6 Known A cells and B cells
13.4 Miscellaneous
13.4.1 Writing pen/marker
13.4.2 Compatibility worksheet
13.4.3 Compatibility report form
13.4.4 Blood bank logbook compatibility label tag
13.5 Blood sample
13.5.1 Blood sample in lavender top tube
13.5.2 Donor blood segment
 SOP
07
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 1 of 4
Date of Next
Subject : BLOOD GROUPING Review
DISCREPANCIES Prepared by A.N.B
1.0 PURPOSE: To resolve discrepancies between ABO forward and reverse grouping, and weak D for
final interpretation of specific blood group.
2.0 SCOPE: This covers all laboratory staff performing blood grouping procedure.
3.0 PROCEDURE:
 SOP
07
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 2 of 4
Date of Next
Subject : BLOOD GROUPING Review
DISCREPANCIES Prepared by A.N.B

DETAILED INSTRUCTION

1.0 Collection of a new sample

1.1 Collect sample in EDTA tube and plain red top tube
2.0 Preparation of new patient red cell suspension
2.1 Prepare a new patient red cell suspension
3.0 Perform ABO forward and reverse blood grouping – refer to page ____
3.1 Repeat the ABO forward and reverse blood grouping
4.0 If still unresolved, proceed to reverse typing resolution of missing antibodies
procedure.
4.1
A. Add 2 more drops of serum/plasma to each tube.
B. Observe for any reaction.
C. If still unresolved, proceed to next step.
4.2
A. Incubate at cold temperature (4◦C - 18◦C) for 15 – 30 minutes.
B. Incubate auto-control (patient red cell + patient serum)
C. If no reaction, discard the solution and proceed to the next procedure.
4.3 Reverse grouping at 37◦C
4.3.1 Incubate known A and B cells for 15-30 minutes at 37◦C.
4.3.2 To each tube, add two drops of pre-warmed serum.
4.3.3 To tube labelled A, add 1 drop of A cells.
4.3.4 Incubate serum at 37◦C with discrepancy for 15-30 minutes.’
4.3.5 To tube labelled B, add 1 drop of B cells.
4.3.6 Spin and interpret results.
4.3.7 If resolved, record all reactions in the worksheet.
 SOP
07
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 3 of 4
Date of Next
Subject : BLOOD GROUPING Review
DISCREPANCIES Prepared by A.N.B

4.4 Forward Grouping --- PREWARM TECHNIQUE (37◦C INCUBATION)

4.4.1 Pre-warm saline at 37◦C for 15 minutes
4.4.2 Label tubes A and B
4.4.3 Prepare patient cell suspension (PCS)
4.4.4 Wash it 3 times with pre-warmed saline
4.4.5 Incubate the PCS at 37◦C for 15 minutes
4.4.6 Do not remove tubes from incubator
4.4.7 Pipette 1 drop anti A to tube labelled A
4.4.8 Pipette 1 drop anti B to tube labelled B
4.4.9 Mix and spin at 3000 rpm for 10 seconds
4.4.10 Interpret and record results.
4.4.11 If resolved, record on the worksheet
4.5 SALINE REPLACEMENT TECHNIQUE – To differentiate between rouleaux and true
agglutination
4.5.1 After routine incubation and resuspension, do the following:
4.5.1.1 Re-centrifuge the serum/cell mixture
4.5.1.2 Decant the supernatant leaving the cell button undisturbed
4.5.1.3 Add 2 drops of saline
4.5.1.4 Re-suspend the cell button gently
4.5.1.5 Observe for agglutination

INTERPRETATION

Rouleaux : Agglutination/aggregates will disappear

True agglutination : Aggregates will remain or will be visible

 SOP
07
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 4 of 4
Date of Next
Subject : BLOOD GROUPING Review
DISCREPANCIES Prepared by A.N.B

4.6 Weak D testing (Du) testing – to confirm Rh negative result

4.6.1 Incubate the tube with the Rh-negative at 37◦C for 15 minutes
4.6.2 Spin at 3000 rpm for 10 seconds and read
4.6.3 If still negative, wash 3 times with NSS
4.6.4 Discard last washing
4.6.5 Add 2 drops of AHG (antihuman globulin)
4.6.6 Spin and interpret results.

INTERPRETATION

Rh negative : No agglutination

Rh positive : Agglutination
 SOP
08
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 1 of 2
Date of Next
Subject : INCOMPATIBLE RESULTS Review
Prepared by A.N.B

1.0 PURPOSE: To prevent blood/blood product wastage. Re-crossmatch shall be done for at least 2
times by two different Med. Tech. before releasing incompatible result.
2.0 SCOPE: This covers all laboratory staff performing the compatibility testing.

3.0 PROCEDURE:
 SOP
08
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 2 of 2
Date of Next
Subject : INCOMPATIBLE RESULTS Review
Prepared by A.N.B

DETAILED INSTRUCTION
1.0 Collection of a new sample
1.1 Collect sample in EDTA tube and plain red top tube
2.0 Selection of new segment
2.1 Use new segment from the donor tubing
3.0 Preparation of new patient red cell suspension
3.1 Prepare a new patient red cell suspension
4.0 Perform crossmatching refer to page____
4.1 Repeat the crossmatching twice
4.2 If still incompatible,
4.2.1 Let another Med. Tech. do another crossmatching using the same sample for
at least two times.
5.0 Verification
5.1 Verify result with another Medical Technologist before releasing the result.
6.0 Documentation
6.1 Record result on the blood bank logbook
7.0 Materials required – refer to SOP #
 SOP
09
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 1 of 3
Date of Next
Subject : ISSUANCE OF BLOOD/BLOOD Review
PRODUCT TO WARD Prepared by A.N.B

1.0 PURPOSE: To ensure the issuance of the right blood/blood product with proper handling and
maintain its good quality from blood bank to the vein of the patient.
2.0 SCOPE: This covers to all laboratory staff and nurses handling the blood product.

3.0 PROCEDURE:
 SOP
09
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 2 of 3
Date of Next
Subject : ISSUANCE OF BLOOD/BLOOD Review
PRODUCT TO WARD Prepared by A.N.B

DETAILED INSTRUCTION

1.0 Receipt of Required Documents and Blood Container

1.1 Upon receipt, the authorized laboratory personnel checks the following :
1.1.1 Official compatibility test result issued by the blood bank
1.1.2 Blood transfusion form which forms part in the compatibility result form.
1.1.3 Appropriate container for transport of blood from the blood bank to the ward.

2.0 Verification of Documents

2.1 MTOD and NOD check the compatibility label, blood unit, compatibility result and blood
transfusion record form as to:
2.1.1 Name of the patient
2.1.2 Blood type
2.1.3 Blood product
2.1.4 Donor unit number
2.1.5 Date of expiry
2.1.6 Completion of data on vital signs monitoring of Blood transfusion Form
2.2 If acceptable, proceed to the next shift
2.3 If not acceptable, defer issuance of blood and resolve the discrepancy.

3.0 Documentation
3.1 The NOD affixes his/her signature on the blood bank logbook as proof of withdrawal.
3.2 The Med. Tech./Lab Aide and the Nurse-on-duty affixer their signature on the compatibility
testing result form, noting the date and time the blood/blood component is issued.

4.0 Issuance of Blood/Blood product

4.1 Med. Tech. on duty issues the blood product to the NOD and place inside its
recommended blood container.
 SOP
09
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 3 of 3
Date of Next
Subject : ISSUANCE OF BLOOD/BLOOD Review
PRODUCT TO WARD Prepared by A.N.B

5.0 Consideration in the issuance of blood/blood product

5.1 Only one unit of Packed Red Blood Cell/Whole blood should be taken at a time for each
patient, except in cases of massive bleeding.
5.2 All blood products must be transported in its recommended blood container.

6.0 Materials required:

6.1 Crossmatched blood/blood product
6.2 Recommended container for blood/blood product
6.3 Compatibility testing result form issued from laboratory
6.4 Blood bank logbook
 SOP
10
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 1 of 2
Date of Next
Subject : RETURN OF CONSUMED Review
BLOOD/BLOOD PRODUCT Prepared by A.N.B

1.0 PURPOSE: To ensure sufficient documentation and proper disposal of consumed blood products.
2.0 SCOPE: This covers to all laboratory staff and nurses handling the blood product.

3.0 PROCEDURE:
 SOP
10
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 2 of 2
Date of Next
Subject : RETURN OF CONSUMED Review
BLOOD/BLOOD PRODUCT Prepared by A.N.B

DETAILED INSTRUCTION

1.0 Receipt of consumed blood/blood product

1.1 Med. Tech. checks the following:
1.1.1 Remaining volume of Consumed blood
1.1.2 Sharp attached to the blood bag like needle and spike
1.1.2.1 Any sharp must be pulled out by NOD before endorsing consumed
blood/blood product to the blood bank.

2.0 Verification of Documents

2.1 Med. Tech. determines the completeness of data on the blood transfusion record form. If
incomplete, return to NOD for data completion.
2.2 If data is already complete, proceed to the next step.

3.0 Documentation
3.1 Med. Tech. records on the lower portion of the blood transfusion form (original and duplicate)
the remaining volume of blood in the blood bag.

4.0 Retention of Documents

4.1 Med. Tech. retains the duplicate copy of Blood Transfusion Form and returns the Original Blood
Transfusion form copy to the ward.

5.0 Disposal of consumed Blood/blood product

5.1 Laboratory staff disposed of properly the consumed blood bag component.

6.0 Materials required:

6.1 Consumed blood/blood product
6.2 Blood transfusion form with complete data
 SOP
11
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 1 of 2
Date of Next
Subject : RETURN OF UNUSED Review
BLOOD/BLOOD PRODUCT Prepared by A.N.B

1.0 PURPOSE: To ensure that the quality of Blood product is maintained after its withdrawal from the
blood bank and its proper disposal when necessary.
2.0 SCOPE: This covers to all laboratory staff and nurses handling the blood product.

3.0 PROCEDURE:
 SOP
11
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 2 of 2
Date of Next
Subject : RETURN OF UNUSED Review
BLOOD/BLOOD PRODUCT Prepared by A.N.B

DETAILED INSTRUCTION

1.0 Return of unused blood product

1.1 Upon receipt, the Med. Tech. checks the time the blood bag was returned.
1.1.1 If within the “30 minute rule”, check the appearance and condition of the blood bag
based on the standard criteria.
1.1.2 If not within the “30 minute rule”, accept the blood but dispose of if properly. Inform
the nurse-on-duty.

2.0 Assessment of the condition of blood/blood product

2.1 No hemolysis
2.2 No clots in the blood product

3.0 Assessment of the blood bag

3.1 No damage or leak
3.2 Portal still intact
3.3 No puncture

4.0 Documentation
4.1 Med. Tech. records on the logbook the date and time of return of the blood/blood product.

5.0 Disposal of unacceptable returned blood unit

5.1 Dispose of properly the returned blood/blood product bag.

6.0 Materials required:

6.1 Return blood component unit
6.2 Blood bank logbooks
6.3 Recommended container for blood unit
6.4 Watch
 SOP
12
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 1 of 2
Date of Next
Subject : RETURN OF INCOMPATIBLE Review
BLOOD/BLOOD PRODUCT TO ISSUING Prepared by
A.N.B
FACILITY

1.0 PURPOSE: To prevent wastage of blood/blood product that are not suitable for transfusion.
2.0 SCOPE: This covers to all laboratory staff and nurses handling the blood product.

3.0 PROCEDURE:
 SOP
12
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 2 of 2
Date of Next
Subject : RETURN OF INCOMPATIBLE Review
BLOOD/BLOOD PRODUCT TO ISSUING Prepared by
A.N.B
FACILITY

DETAILED INSTRUCTION

1.0 Incompatible result

1.1 Med. Tech. issues incompatible result and inform the nurse-on-duty.
1.2 Nurse informs the patient/watcher about the incompatible result.

2.0 Preparation of transmittal form

2.1 Med. Tech. prepares transmittal form for the return of incompatible blood unit

3.0 Preparation of blood product for transport

3.1 Med. Tech informs the patient/watcher to provide a pack of ice and recommended container.
3.2 Seal the container properly.
3.3 Attach the accomplished transmittal form on top of the container cover.
3.4 Advice the patient’s watcher on how to handle the blood unit during transportation.

4.0 Documentation
4.1 Med. Tech. records on the logbook the date and time of return of the blood/blood product

5.0 Disposal of unacceptable returned blood unit

5.1 Dispose properly the returned blood/blood product bag.

6.0 Materials required:

6.1 Returned blood component unit
6.2 Blood bank logbook
6.3 Recommended container for blood unit
 SOP
13
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 1 of 2
Date of Next
Subject : REASSIGNMENT OF Review
BLOOD/BLOOD PRODUCT Prepared by A.N.B

1.0 PURPOSE: To prevent wastage of blood/blood product with deferred/cancelled transfusion order.
2.0 SCOPE: This covers to all laboratory staff with direct access to the reassigned blood product.

3.0 PROCEDURE:
 SOP
13
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 2 of 2
Date of Next
Subject : REASSIGNMENT OF Review
BLOOD/BLOOD PRODUCT Prepared by A.N.B

DETAILED INSTRUCTION

1.0 Receipt of required documents

1.1 Med. Tech. receives the following documents from the NOD.
1.1.1 “Pag-uyon” form duly signed by the patient/watcher.
1.1.2 Compatibility requisition form of the new recipient of the blood/blood product.
1.2 Reassignment of blood/blood product shall be applicable up to second time only.

2.0 Documentation for reassignment of blood/blood product

2.1 Med. Tech. records the name of the new recipient on the Blood bank logbook.

3.0 Proceed to SOP # 3 – Compatibility Testing Request Form

4.0 Proceed to SOP # 4 – Collection and labelling of blood sample for compatibility testing

5.0 Proceed to SOP # 5 – Validity and retention of blood sample

6.0 Proceed to SOP # 6 – Compatibility Testing

7.0 Materials required

7.1 Pag-uyon form
7.2 Pag-tugot form
 SOP
14
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 1 of 4
Date of Next
Subject : BLOOD TRANSFUSION Review
REACTION Prepared by A.N.B

1.0 PURPOSE: To monitor suspected transfusion reactions and other transfusion-related adverse
events.
2.0 SCOPE: Guideline for the physicians, nurses, and blood bank personnel in the management of
transfusion reaction.

3.0 PROCEDURE:
 SOP
14
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 2 of 4
Date of Next
Subject : BLOOD TRANSFUSION Review
REACTION Prepared by A.N.B

DETAILED INSTRUCTION

1.0 Receipt of call from Nurse on-duty, Re: Transfusion Reaction

1.1. The medical technologist on-duty upon receipt of the call or notification for a suspected
transfusion reaction, issues a Blood transfusion reaction registry form to the attending
physician/nurse to fill up the following:
1.1.1. Patient’s data
1.1.1.1. Patient’s full name
1.1.1.2. Age and sex
1.1.1.3. Date of birth
1.1.1.4. Hospital number
1.1.1.5. Ward
1.1.2. Date and time when transfusion was started and ended.
1.1.3. Symptoms
1.1.3.1. Hives
1.1.3.2. Chills
1.1.3.3. Rashes
1.1.3.4. Itchiness
1.1.3.5. Nausea
1.1.3.6. Hematuria
1.1.3.7. Pain
1.1.3.8. Fever
1.1.3.9. Vomiting
1.1.4. Actions done: Whether,
1.1.4.1. Anti-histamine given
1.1.4.2. Medicine given
 SOP
14
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 3 of 4
Date of Next
Subject : BLOOD TRANSFUSION Review
REACTION Prepared by A.N.B

2.0 Submission of Blood unit and Transfusion reaction registry form to the Blood Bank.
2.1 For investigation of a suspected transfusion reaction, the Nurse on-duty must
immediately send to the blood bank the following:
2.1.1 The blood unit that is for investigation of transfusion reaction
2.1.2 The compatibility result
2.1.3 Blood transfusion form
2.2 Collect a post-transfusion sample from the patient in Lavender top (EDTA) and Red top
(Plain) tubes and record time of collection.

3.0 Transfusion reaction study

3.1 The MTOD performs the investigation study of suspected transfusion reaction.

3.2 Review and recall all data on the compatibility result, sample tube, record books and
worksheet and blood donor unit and labels.

3.3 Check for any clerical error as to patient’s identification and donor unit and blood group.

3.4 Record pertinent information on Blood Transfusion Reaction Registry form.

3.5 PERFORM THE FOLLOWING ON THE PRE- AND POST-TRANSFUSION SAMPLE:

3.5.1 Do a visual check for hemolysis to serve as a baseline.
3.5.2 ABO and Rh typing (Forward and Reverse) on both
3.5.2.1 Patient’s sample
3.5.2.2 Donor unit sample
3.5.3 Compatibility testing
 SOP
14
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 3 of 4
Date of Next
Subject : BLOOD TRANSFUSION Review
REACTION Prepared by A.N.B

3.6 Perform Direct Antiglobulin (DAT) on post-transfusion sample.

3.6.1 If positive, perform DAT on pre-transfusion sample and do additional tests such
as:
3.6.1.1 Hemoglobin and hematocrit
3.6.1.2 B1B2 and LDH
3.6.1.3 Urinalysis, and include Urobilinogen after 6 hours

4.0 Documentation
4.1 Diagnosis and final report will be referred to the Blood Bank Consultant/s.
4.2 A final report is submitted to the attending physician. This report is attached to the chart
of the patient and a duplicate copy retained in the Blood bank.
 SOP
15
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 1 of 2
Date of Next
Subject : Hospital Blood Pool Usage Review
Prepared by A.N.B

1.0 PURPOSE: To provide standby Blood/blood products to be utilized during urgent or emergency
cases only. Evaluation on the urgency to transfuse will only be through the
Consultant/Physician on-duty. All elective cases patients will secure blood from the
outside Blood bank facility.
2.0 SCOPE: This covers all laboratory staff, nurses, and physicians.

3.0 PROCEDURE:
 SOP
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 1 of 2
Date of Next
Subject : Hospital Blood Pool Usage Review
Prepared by A.N.B

DETAILED INSTRUCTIONS:

1.0 Assessment
1.1 Physician managing/handling the patient will assess the urgency for the need to
transfuse blood component.

2.0 ASAP Order

2.1 Physician make written order on patient’s chart for ASAP compatibility testing

3.0 Requisition
Nurse on-duty does the following:

3.1 Carry out physician’s order for ASAP compatibility testing.

3.2 Proceed to the laboratory and forward the request form.
3.3 Inform the patient/watcher to replace the Blood component transfused to the patient
before going home/discharge.

4.0 Documentation
Medical Technologist does the following:

4.1 Record on the Compatibility logbook the name of the patient as recipient of the blood
component withdrawn from the Hospital Blood Pool.
4.2 Record on the Blood Pool logbook the withdrawal and recipient of the blood component.

5.0 Compatibility Testing – refer to SOP on Compatibility testing.

 SOP
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 1 of 2
Date of Next
Subject : FEFO – First to Expire, First Out Review
Scheme Prepared by A.N.B

1.0 PURPOSE: To minimize wastage of blood/blood product from hospital blood pool.
2.0 SCOPE: This covers all laboratory staff, nurses, and physicians.

3.0 PROCEDURE:
 SOP
COMPOSTELA VALLEY PROVINCIAL Number
HOSPITAL Effective
01/01/15
Date
Department of Laboratories
Approval
Date
STANDARD OPERATING PROCEDURE Page 2 of 2
Date of Next
Subject : FEFO – First to Expire, First Out Review
Scheme Prepared by A.N.B

DETAILED INSTRUCTIONS:

1.0 Upon the endorsement of blood/blood products to the laboratory, please refer to the
SOP on the Acceptance of Blood/blood product.

2.0 FEFO scheme

2.1 Medical technologist does the following:

2.1.1 Evaluate the similarity and difference of the expiration date between the Pooled
blood and the newly endorsed blood/blood product which is for deposit of the
patient.
2.1.2 Select which blood unit expires first. It may either be from the pooled blood or the
blood component deposited by the patient himself.
2.1.3 Assign the said unit to the patient for compatibility testing.

3.0 Documentation
3.1 Record on the Compatibility logbook the blood/blood product which expires first under
the name of the patient.
3.2 Simultaneously, record on the Blood Pool logbook the date of withdrawal and the
recipient of the blood/blood product.

4.0 Compatibility testing – refer to SOP on Compatibility testing.

 DEFINITION OF TERMS

Blood/Blood Products - whole blood or the constituents/components such

as plasma or platelets that are used in
replacement therapy or transfusion.
Authorized Personnel - Medical technologist, phlebotomist that has
sufficient training and who is allowed by the
health facility to perform particular task that
require definitive skill.
Non-conformance - Failure to comply with a requirement of a blood
bank quality system.
Conformance - Act of adherence to a certain specification,
standard or guideline of a blood bank quality
system.
Co-identifier - person/s who prove to be true by demonstration
of evidence or testimony that he knew the exact
identity of the patient.
Discrepancy - a conflict or variation between facts which leads
to confusion of information.
Pag-uyon form - form signed by the owner of a particular
blood/blood product that he is voluntarily donating
his blood to the CVPH-Pantukan upon discharge.
Pag-tugot form - an agreement between the two individuals
described as the owner of the blood/blood
product and the recipient of the blood. It
stipulates that the owner agrees to re-assign his
blood to another patient called the recipient of the
blood and that whatever transpired between the
two parties the CVPH-Pantukan has not in any
way got involved in their agreement.

ACRONYM

NOD - Nurse on-duty

MTOD - Medical technologist on-duty.