May 3, 2021

Standard 7: What you need to know

In the lead up to organisation wide Accreditation from 24-28 May 2021, each week Northern Health will be focusing on a different Standard. You will hear from the Chairs of each Standard Committee on what you need to know.

This week we spoke to Dr Wanda Stelmach, Chief Medical Officer, about Standard 7: Blood Management

What is this Standard about?

Standard 7 deals with blood and blood products whether it is the taking of blood samples from patients or the giving of blood and blood products to patients. Blood is a precious resource. It is a product that is altruistically gifted by members of the community to support those members in the community who need it most. Blood products must therefore be used appropriately and safely. Blood samples must also be appropriately managed so that our patient community is not impacted adversely by the need to take multiple samples.

At Northern Health, this Standard looks like….

  • Blood is considered a precious resource and will be used appropriately and safely
  • Right blood to the right patient for the right reason
  • Correct and MATCHING labelling of blood tubes and request slip
  • Consent – information brochure and written consent
  • Blood Product Administration Chart is your guide and documentation tool
  • Blood Safe training for all staff who handle blood, blood products and blood samples
  • Correct and safe blood storage
  • Minimized wastage

What are the top 5 ways staff can be prepared for Accreditation against this Standard?

The five key messages from Standard 7 are:

  • Effectively optimizing and conserving a patient’s own blood, reducing the unnecessary risk of exposure to blood products and associated adverse events
  • Making clinical decisions ensuring all treatment options, and their risks and benefits, are considered before deciding to transfuse
  • Safely administering the products to the intended recipient.
  • Storing and disposing of blood and blood products correctly.
  • Reporting and investigating any adverse reactions or incidents.

What are the top 5 questions staff needs to be able to answer about this Standard?

  1. Do you know the governance structure/Committee that oversees the safety and quality systems for Blood management at Northern Health?
  2. What is the mandatory training requirements for the Staff involved in Blood Management, the frequency of training, and where can you access these training?
  3. How do we involve the patient in their care with regards to blood management?
  4. What is Patient Blood Management?
  5. What do you do when a patient experiences a reaction to a blood product?

Is there anything else you would like staff to know about this Standard?

The Zero tolerance program in Blood Management rejects samples that do not meet the labelling requirement for pre-transfusion sample collection and request for blood and blood products. This means if the tube and the request information don’t match the sample is rejected and the patient has ANOTHER UNECESSARY venesection!


  • Patient’s 3 point ID must match with the specimen tube and request form.
  • The collector’s signature or initials and date of collection on the request form must be identical to the sample label.

To learn more about Standard 7, please see the Intranet.