Challenge 5

Anemia and Transfusions

Anemia is a condition marked by a deficiency of red blood cells (RBC) or of hemoglobin (Hb), which is the protein present in red blood cells that allows for the transport of oxygen through the body. Due to the lack of oxygen, a patient can experience fatigue, pale skin, dizziness, nausea, and many other symptoms. RBC transfusions are administered to patients during active bleeding, chronic blood loss or poor production in order to increase the body’s oxygen carrying capacity. Despite the perceived benefit, many RBC transfusions have been deemed unnecessary resulting in risk or harm and defined as “overuse”.

Each Actionable Patient Safety Solutions (APSS) includes an Executive Summary Checklist, Performance Gap, Leadership Plan, Practice Plan, Technology Plan and Metrics. Please click Download below to view the full document. A preview of the Executive Summary is offered below.

Executive Summary Checklist

Errors in the use of blood products are a significant cause of hospital patient morbidity and mortality. To eliminate these errors, we must implement an effective Patient Blood Management program, including the following actionable steps:

  • A Commitment from hospital leadership to support a Patient Blood Management program that closes the performance gap by reducing unnecessary transfusions while speeding up needed blood transfusion and care for patients who truly need it.
  • Clinical and safety leadership endorse the plan and drive implementation across all providers and systems.
  • Establish the Patient Blood Management Committee, which replaces the traditional hospital transfusion committee, and appoint an MD chairperson to be responsible and accountable for leading this group.
  • On a monthly basis, distribute the blood product usage report by clinicians across the hospital to hospital leaders.
  • Develop a Patient Blood Management education program for emergency and elective hospital admissions, targeting medical students, physicians, nurses, pharmacists and other healthcare staff.
  • Implement interdisciplinary blood conservation modalities, including:
    • Reductions of unnecessary laboratory tests, frequency of blood sampling, and “discard” volumes.
    • A consistent protocol for preoperative management of platelet inhibitors and other anticoagulants.
    • Technology that has been shown to improve patient care, such as continuous non-invasive hemoglobin monitoring and red cell recovery technology in the operating room (OR).
  • Establish protocols for anemia management, including:
    • Screen, diagnose and appropriately treat anemia prior to surgery, allowing adequate lead time to correct the anemia before surgery.
      • Identify patients at risk for needing transfusion.
      • Increase hemoglobin levels before surgery.
      • Minimize the risk of hitting levels that require blood transfusions.
    • When appropriate, establish single unit transfusion policy and advocate for restrictive transfusion practices.
    • Document hemoglobin levels before the transfusion of each RBC unit.
    • Consider alternative therapies to RBC transfusions, such as intravenous iron or erythropoietin stimulation agents (ESAs).
  • Continuously monitor the effectiveness of the Patient Blood Management program, and use the results of this monitoring in medical staff educational sessions as a part of Continuous Quality Improvement (CQI).


Restrictive transfusion strategies can reduce the risk of receiving RBC transfusions by 39%, and are associated with reductions in hospital mortality.1

Carson JL, Carless PA, Hebert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD002042.

About 0.5% to 3% of all transfusions result in some adverse events.2

Kumar, P., Thapliyal, R., Coshic, P., & Chatterjee, K. (2013). Retrospective evaluation of adverse transfusion reactions following blood product transfusion from a tertiary care hospital: A preliminary step towards hemovigilance. Asian Journal of Transfusion Science, 7(2), 109–115.

With 15 million RBC units transfused per year, the estimated risk for death due to hemolysis is 1:1,250,000 or 8 per 10 million RBC units.3

Federowicz I, Barrett BB, Andersen JW, Urashima M, Popovsky MA, Anderson KC. Characterization of reactions after transfusion of cellular blood components that are white cell reduced before storage. Transfusion. 1996;36: 21-8. [PMID: 8607149].

Transfusion-related fatalities due to hemolysis reported to the U.S. Food and Drug Administration averaged 12.5 deaths per year from 2005 to 2010.4

Carson, J. L., Grossman, B., Kleinman, S., Tinmouth, A. T., Marques, M. M., Fung, M. K., … Djulbegovic, B. (2012). Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB. Annals of Internal Medicine. doi:10.7326/0003-4819-156-12-201206190-00429