1 No Sop General Nformetion

STANDARD OPERATING PROCEDURE-01
BLOOD BANK, CARE HOSPITALS, BHUBANESWAR

VERSION 01
EFFECTIVE DATE
SOP
General Information REVIEW PERIOD 2 years
01
PAGE NO. Page 1 of 14
FUNCTION – Operation to function

LOCATION – Information Document
DISTRIBUTION – Master File
1.SCOPE AND APPLICATION
All the patients undergoing treatment at care hospital ,outside hospital and nursing home.
1. PURPOSE
 Blood transfusion service (BTS) ,although a vital part of National Health Services.
 To facilitate & emphases on the rational use of blood and blood products.
 Detection , reporting & evaluation of Blood Transfusion Reaction.
 To minimize Transfusion transmitted infections (TTI).
 Comply with the government statutory requirements.
1. RESPONSIBILITY
 The overall responsibility for formulating ,revising , implementing, provisioning of education

material to Blood Bank staff & clinicians, training of trainers /supervisors concerned hospital
personnel monitoring for this policy is the responsibility of the in charge of Blood Bank in the
hospital.
 Care Hospital formed a transfusion committee . This committee is primarily responsible to monitor,
analyze and to take corrective measures for all the transfusion policy.
 Committee has designed a Blood Transfusion Reaction form which is circulated to all patient care
areas.
1 1 1
PREPARED BY VERIFIED BY FORWARDED BY APPROVED BY
DATE
NAME MR. B. MAJHI DR. D. P. RATH DR. C. BOSE MR.G.KHURANA
DESIGNATION TECH.SUPERVISOR B.B.O. M.S. FCOO
SIGNATURE

VERSION 01
EFFECTIVE DATE
SOP
01

 Committee is responsible to educate all HODS about blood transfusion reaction form.
 All individual HODS of the related units are directly responsible for implementation provisioning
of education material to patients workers, training of supervisors concerned hospital personnel
 and monitoring reporting for this policy in their respective areas of work.
 guidance from and coordinate with the chairperson transfusion committee. They also monitor that
all the reactions are reported to committee promptly whenever such incidents happen.
 Appropriate Blood selection and its documentation is the responsibility of the Blood Bank staff.
 The ordering clinician reviews the risks and benefits of selected blood & components and
documents patients or guardian's informed consent in the consent form.
 The attending nurse verifies the presence of this documentation before administration of the blood.
 Monitoring of patient is done by the staff nurse trained in blood transfusion.
 Continuous monitoring and reassessment of patient undergoing blood transfusion during and after
the procedure is done. This is the responsibility of the monitoring nurse as well as the physician
consultant such transfusion.
 To ensure the availability of emergency resuscitation equipment as standby to rescue the patients
from BTR is the responsibility of the attending nurse.
DATE
SIGNATURE

VERSION 01
EFFECTIVE DATE
SOP
01

 The HOD of each department administering blood transfusion is responsible for ensuring that
departmental policies and procedures are applicable and consistent with this hospital policy.
 Blood bank officer is responsible for planning, conducting, complain and reporting the patients
satisfaction survey and Employees satisfaction surveys. This is an ongoing activity and is reported on
monthly basis.
 4. Responsibilities and Authority.
Blood Bank Officer
1. Blood bank officer is the incharge HOD to supervise overall function of the department.
2. To allocate duty among the staff.
3. To supervise and monitor all the administrative work.
4.. To ensure all the safety parameters are met adequately to control the infection
5. To monitor and review the statutory requirements of Blood Bank and keep all the documents
and record update.
6. To counsel with the patients doctors as an when it is necessary.
7. To manage donors adverse reaction .
8. Responsibility to donor selection , medical & physical examination to fit for donation.
9. He is implement the general policy, administration & procedure.
DATE
SIGNATURE

VERSION 01
EFFECTIVE DATE
SOP
01

B. Responsibility : Technical Supervisor
1. Overall Supervision & manage day to day activities as a incharge of blood bank.
2. To supervise and timely report of quality control and timely reporting to the Blood Bank HOD.
3. To supervise the overall responsible to follow the frequency calibration & logbook maintaining
by bio- medical services.
4. Prepare the work flow chart as per job description & management the leave.
5. To make the sift duty roster among the staff & placed the indent inventory to store.
6. Management & corresponding overall compliance to SBTC & OSAC.
7. To supervise all work and staff management in absence of Blood Bank Officer.
8. To carry out the EQAS programme and comply with other Hospital.
9. All SOP review and implementation as per guide line of SBTC ,NACO ,NBTC & NABH
reference.
C. Responsibility : Chief Technician
1. To supervise the functions of the technicians.
2. To monitor the investigation and proper documentation before dispatch.
3. To prepare the Blood component and separation.
4. To take monthly SWAB surveillance and take action accordingly.

4
DATE
SIGNATURE

VERSION 01
EFFECTIVE DATE
SOP
01

5. To indent the necessary items from the stores in case of emergency.
6. To maintain all stock and verify it.
7. To maintain all the register and records.
8. To Calibrate the equipment and other instrument through bio-medical engineer.
9. To carry out and supervise the special investigation & transfusion reaction .
D. Responsibility : Technician/SR.Technician
1. To maintain quality control all records duly attached to lab report.
2. To cross check the requisition form with blood sample thoroughly.
3. To do the investigation before collection and collect the blood after necessary formality.
4. To store the blood properly and do the screening test and necessary to rapid test.
5. To co-ordinate with all departmental activities respectively.
6. To maintain the register and other records.
7. To do the cross-matching , prepare blood component and to collect therapeutics phlebotomy when
required to Performed change of shift duty in emergency.
8. Maintain the all relevant register and summary in shift of night duty with maintain of
temperature of blood storage cabinet.

5
DATE
SIGNATURE

VERSION 01
EFFECTIVE DATE
SOP
01

9. To issue the blood and components and ensure a smooth work among the department.
10. Responsibility to all discarded blood autoclave by attendant and guide for waste management.
E. Responsibility : Staff Nurse
1. It is responsibility to staff nurse registration ,selection & counseling to the blood donor with
preliminary medical checkup.
2. It is the responsibility to collection of blood and take care in post donation .
3. Management in donors adverse reaction .
4. To ensure all material used in donor collection kept in collection tray.
5. To indent& control all pharmacy items in necessary .
6. Required emergency medicine for donor collection room to be control.
F. Responsibility : counselor
1. It is the responsibility to receiving donors requisition, registration and counseling to donor
before collection of blood.
2. To maintain all blood and its component record entry in computer for required of reporting
when necessary.
3. Prepare all statistic report when required to submit and report return for higher authority.
4. To maintain master register for day to day functioning of work .
5. To prepare monthly statistic summary submit to HOD for further disposal.
6. To keeping all the records storage for the period of 5 years.
6
DATE
SIGNATURE

VERSION 01
EFFECTIVE DATE
SOP
01

G. Duties Of Attendant
1. To given refreshment to donor and assist when in blood collection.
2. Maintain cleanness of area ,instrument, equipment and all blood storage refrigerator .
3. Collect store indent and transport of equipment .
4. Doing discarded blood to autoclaving and disposable to waste management .
5. Keeping all label,records & forms are in proper as per sigma .
6. Storage all samples donor & recipient for period of 7 days after issue of blood.
7. To cleanness all using samples and kept in hot air oven for sterilization.
8. To perform the change of shift duty in emergency.
5. Blood bank policy :
The blood bank should function under the direction of a license qualified medical officer having
responsible for medical, technical and administrative service obtaining license by state drug
controller, approved by drugs controller general (India) which should be regulated by drugs and
cosmetics Act and rules.
1. Blood should not be transfuse unless it has been obtained TTI tested and compatibility
between the donors and recipient.
2. Blood Transfusion is done in the supervision of a doctor.

7
DATE
SIGNATURE

VERSION 01
EFFECTIVE DATE
SOP
01

3. Incase of Emergency where there is risk of life of patient, blood transfusion can be only done
without screening and compatibility tests if treating consultant /physician gives undertaking.
4. Blood once issued would not be accepted after half an hour of issue or in case of any physical
sign of clotting or puncture of bag is found.
5. Consent of donor and recipient is must.
6. Quality Assurance System:
The hospital gives great emphasis to maintain quality in the Blood bank follows the following
standards to ensure the same.
1. Qualified and Adequate staffs - the blood bank is managed by well experienced and qualified
staffs as Blood bank officer, Technical supervisor ,Chief technician,Technicians ,Staff nurse,
2. councilor
3. Regular preventative and Annual Maintenance including periodical calibration of the various
equipment are being done as per planned schedule .
4. Continuous Training is provided to the staffs on monthly basis.
5. Quality control check of reagents and anti sera and temperature recording of fridges and other
equipment are being carried out daily basis and record of the same maintained.
6. Blood and its component and other measure equipment used in procedure are tested for quality
control in monthly basic.
8
DATE
SIGNATURE

VERSION 01
EFFECTIVE DATE
SOP
01

7. The blood banks should establish and maintain a quality assurance system based on the
following required:-
 Organization and Management
 Resources
 Equipment
 Supply and customer issues
 Process control
 Documents and records.
 Deviations nonconformances and complications.
 Service provide by Blood Bank
SL.NO SERVICES
1 Blood grouping and Rh Typing (Tube /Gel ) Tech.
2 Screening Test of Donor (HIV, HBS Ag,HCV, VDRL& Malaria Test)
3 Indirect Coomb’s test (ICT/IAT)
4 Direct Coomb’s test (DCT/DAT)

9
DATE
SIGNATURE

VERSION 01
EFFECTIVE DATE
SOP
01

5 Cross Matching (Compatibility Test)
10
DATE
SIGNATURE

VERSION 01
EFFECTIVE DATE
SOP
01

6 Packed Red Blood Cells (PRBC)
7 Platelet Rich in Plasma (PRP)
8 Fresh Frozen Plasma (FFP)
9 Platelet Concentrate (Random) (RDP)
10 Washed RBCS
11 Cryoprecipitate (CRyO)
12 Leucocyte Depleted (PRBC)
13 Leucocyte Reduce (PRBC)
14 Therapeutics Phlebotomy
15 Autologous Blood Transfusion
16 Whole Human Blood (W/Blood)
11
DATE
SIGNATURE

1 No Sop General Nformetion

Uploaded by

Copyright:

Available Formats

1 No Sop General Nformetion

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

1 No Sop General Nformetion

Uploaded by

Copyright:

Available Formats

STANDARD OPERATING PROCEDURE-01

BLOOD BANK, CARE HOSPITALS, BHUBANESWAR

FUNCTION – Operation to function

1.SCOPE AND APPLICATION

 Detection , reporting & evaluation of Blood Transfusion Reaction.

 To minimize Transfusion transmitted infections (TTI).

 Comply with the government statutory requirements.

 The overall responsibility for formulating ,revising , implementing, provisioning of education

DESIGNATION TECH.SUPERVISOR B.B.O. M.S. FCOO

BLOOD BANK, CARE HOSPITALS, BHUBANESWAR

FUNCTION – Operation to function

 Monitoring of patient is done by the staff nurse trained in blood transfusion.

PREPARED BY VERIFIED BY FORWARDED BY APPROVED BY

DESIGNATION TECH.SUPERVISOR B.B.O. M.S. FCOO

BLOOD BANK, CARE HOSPITALS, BHUBANESWAR

FUNCTION – Operation to function

 4. Responsibilities and Authority.

Blood Bank Officer

2. To allocate duty among the staff.

3. To supervise and monitor all the administrative work.

6. To counsel with the patients doctors as an when it is necessary.

7. To manage donors adverse reaction .

9. He is implement the general policy, administration & procedure.

PREPARED BY VERIFIED BY FORWARDED BY APPROVED BY

DESIGNATION TECH.SUPERVISOR B.B.O. M.S. FCOO

BLOOD BANK, CARE HOSPITALS, BHUBANESWAR

FUNCTION – Operation to function

by bio- medical services.

6. Management & corresponding overall compliance to SBTC & OSAC.

C. Responsibility : Chief Technician

1. To supervise the functions of the technicians.

2. To monitor the investigation and proper documentation before dispatch.

3. To prepare the Blood component and separation.

4. To take monthly SWAB surveillance and take action accordingly.

DESIGNATION TECH.SUPERVISOR B.B.O. M.S. FCOO

BLOOD BANK, CARE HOSPITALS, BHUBANESWAR

FUNCTION – Operation to function

6. To maintain all stock and verify it.

7. To maintain all the register and records.

8. To Calibrate the equipment and other instrument through bio-medical engineer.

1. To maintain quality control all records duly attached to lab report.

2. To cross check the requisition form with blood sample thoroughly.

5. To co-ordinate with all departmental activities respectively.

6. To maintain the register and other records.

temperature of blood storage cabinet.

DESIGNATION TECH.SUPERVISOR B.B.O. M.S. FCOO

BLOOD BANK, CARE HOSPITALS, BHUBANESWAR

FUNCTION – Operation to function

E. Responsibility : Staff Nurse

before collection of blood.

4. To maintain master register for day to day functioning of work .

5. To prepare monthly statistic summary submit to HOD for further disposal.

6. To keeping all the records storage for the period of 5 years.

DESIGNATION TECH.SUPERVISOR B.B.O. M.S. FCOO

BLOOD BANK, CARE HOSPITALS, BHUBANESWAR

FUNCTION – Operation to function

1. To given refreshment to donor and assist when in blood collection.

3. Collect store indent and transport of equipment .

4. Doing discarded blood to autoclaving and disposable to waste management .

5. Keeping all label,records & forms are in proper as per sigma .