LHMRH Blood Bank (2022)

BLOOD BANK ENDORSEMENT

This endorsement does not contain the complete work instruction.
If information is not available in this document, refer to Work Instruction.

Endorsed By: Amoy, N., Alsiyao, M., Aranca, D., Backian, J., Bautista, P., Bawing, J., Bernales, J., Estillore, S.,
Gamboa, J., Gualba, J., Haluber, A., Lahaylahay, M., Lao-lao, V., Lawat, W., Medina, K., Nacin, G., Oya, N.,
Pagnas, F., Raz, L., Sunga, A.
Endorsement Date: 15 November 2022

TABLE OF CONTENTS

General Reminders ____________________________________ 1

Screened and Crossmatched Blood Units ____________________________________ 3
Refrigerator
Procedures (Processing Room)
A. TTI Screening and Validation of Blood Unit’s ____________________________________ 4
Blood Type
B. Component Preparation ____________________________________ 6
C. Compatibility Testing (Crossmatching) ____________________________________ 7
D. Blood Type Specific Testing (FFP and PC) ____________________________________ 10
E. Releasing Blood Units ____________________________________ 11
Donors Rooms ____________________________________ 13
OTHER RESPONSIBILITIES
F. Inventory of Blood Units ____________________________________ 15
G. Preventive Maintenance and Temperature ____________________________________ 16
Monitoring
H. Housekeeping ____________________________________ 16
I. Warding and Laundry ____________________________________ 17
DAILY GENERAL ENDORSEMENTS ____________________________________ 18

GENERAL REMINDERS!

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LHMRH Blood Bank (2022)
➮ Standard Operating Procedure
o These are filed properly near the reception area.
o Read the compiled procedures for RCS Preparation, crossmatching
procedure, IAT, DAT, and other procedures.
o Always ask the staff or refer to the blood bank section’s SOP when uncertain
on what to do.
➮ Report of Erroneous Recordings
o AVOID SUPERIMPOSITIONS!. Whenever one commits mistakes in
writing results, patient information, blood bag labels, etc., cross out the
error with a vertical line and sign with your initials.
o Log these mistakes on your own records of erroneous entry and let the staff
on duty sign.
➮ Logbooks
o When filling up necessary informations in different logbooks avoid leaving
blank spaces before or after the space provided.
➮ MTI Endorsement Logbook
o Properly log all tasks that need to be endorsed for the next MTIs to be on
duty.
o Check the endorsement logbook and make sure to re-endorse task/s that
were not accomplished during your duty.
o Endorsements are always done WRITTEN and VERBALLY every after shift.
➮ Blood Bag Labels/Tags, Blood Donor Screening Result
o COLOR CODING
“A” = Blue
“B” = Yellow
“O” = White
“AB” = Pink
o Check component indicated in the tags/papers (i.e. packed red blood cell,
platelet concentrate, fresh frozen plasma).
➮ Printing Results and Needed Documents
o Always double check the information entered before printing.

⚠️
o Never forget to put a comma after last names and day of the dates.
For the FFP TTI form, DO NOT type the date of the day (leave the date
blank), WAIT for the release of the unit before writing the date.
➮ Inventory of Supplies
o Found on top of the TTI machine.
o Update every time one opens new reagent bottles, cleaning supplies, etc.
➮ Mobile Blood Donation (MBD)
o Make sure that all the things needed are ready the day before the said date
of MBD.
o Night Duty: Check or Prepare a sharp and slides containers or bottles for
MBD with 1:10 dilution of bleach and a container for applicator sticks then
place it in beside the MBD supplies.
➮ Crossmatching centrifuge
o centrifuge for STAT and ROUTINE crossmatching are different

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LHMRH Blood Bank (2022)
o ROUTINE: BIOLAB centrifuge for crossmatching and TTI samples
PARAMETERS MINUTES RPM
1 1 1500
2 2 1500
3 3 2500
4 4 4500
5 5 5000
6 6 6500
7 7 10000

o STAT: HETTICH centrifuge for crossmatching and TTI samples

PROGRAM MINUTES RPM
1 1 1500
2 3 4500
3 15 6500

➮ Storage of Samples in Panasonic 2 Refrigerator

o Correct order of storing are observed for DAY 1-DAY 8:
● 1st (front row): all crossmatching tubes
a. Patient’s mother tube
b. Patient’s RCS
c. Donor’s tube (blood from segment)
d. Donor’s RCS
● 2nd (middle row): segments of released blood products -
● 3rd (back row): tti tubes and daily “A” and “B” cells
a. Donor’s edta tubes
b. Donor’s RCS
c. Mother tube of prepared RCS (a cells and b cells)

SCREENED AND CROSSMATCHED BLOOD UNITS’ STORAGE

General Rules
FIRST IN FIRST OUT (FIFO) from left to right facing
the refrigerator
○ Be careful when taking out blood units for
crossmatching and releasing.
○ Do not move the units from the boxes that they were
placed in.
○ Use something to make sure partially filled boxes with
units stay still (Boxes at cabinet 3 may be used)

NOTE: A blood compatibility tag must be placed immediately on a

blood unit for crossmatching after acquiring the needed segment.
NEVER let the unit stay outside the refrigerator for long, at most
10 minutes.
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LHMRH Blood Bank (2022)

STORAGE OF BLOOD UNITS

○ After newly collected blood units have stand at room temperature for about an hour,
they are stored inside the refrigerator according to blood type.
○ Place new units at the back of the box found on the farthest right (facing the
refrigerator) or at the back most, or at the refrigerator found in the intern’ quarters.

STORAGE OF UNSCREENED BLOOD UNITS

- Newly collected blood units are not stored in the blood pool when they are
unscreened.
○ Whole Blood and Packed Red Blood Cells (PRBC): When the newly collected/
prepared blood units are not done for TTI screening place them in the Quarantine
Box until they are screened properly then that is only time they are stored in each
respective blood type pool.
- Quarantine/Unscreened Blood Boxes are located at the bottom of refrigerators
for whole blood, below AB WB.
○ Fresh Frozen Plasma (FFP) : After the FFP component is prepared and TTI Screening
are yet to be done place a “UNSCREENED” Tag on the unit before it stored.
○ Platelet Concentrate (PC): After the PC component is prepared and TTI Screening are
yet to be done place a “UNSCREENED” Tag on the unit before it is placed in the
agitator upside down and separated from the screened PC of the same blood type.

BLOOD UNITS FOR COMPATIBILITY TESTING (CROSSMATCHING)

○ Always check if the serial number of the TTI result form matches the serial number
attached on the blood bag and from the donor’s logbook to make sure it is the correct
unit.

PROCEDURES (PROCESSING ROOM)

A. TTI SCREENING AND VALIDATION OF BLOOD UNIT’S BLOOD TYPE
1. Receive EDTA Tube
a. Receive EDTA tube labelled with the donor’s name, blood type and blood bag
serial number
2. Malaria Test
a. Get the test kit for Malaria
b. Label the kit with the last 4 digits of the serial number or the whole serial
number
c. Drop 5uL of whole blood + 2 drops of buffer (procedure for this step is
attached on the wall)
d. After 20 minutes and the results become visible, let the staff on duty recheck

3. Centrifuge
a. Centrifuge EDTA tube for 15 minutes at 6500 RPM (program 3)

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LHMRH Blood Bank (2022)
4. TTI Machine
a. Get a rack and place the tube (open cap)
b. Click the following:
I. Order register
II. Sample rack
c. Type the following:
I. Rack number
II. Sample number: Last 4 digits of the serial number
d. Click the necessary tests to be run
e. Click “next sample” or “OK”, then start process by clicking “start” or the blue
button
5. Blood Typing
a. Once the EDTA tubes have been ran by the machine, the EDTA tube is taken
for blood typing
b. Prepare your set-up:
I. Bring out typing sera
II. Get 6 tubes near the centrifuge for: RCS, A, B, D, AC, BC
III. Label the tubes with the serial number and the date of performance
c. Using a Pasteur pipette, pipette 2 drops of plasma/serum into the AC and BC
tubes then 1 drop of packed RBC into the RCS tube
I. After transferring 1 drop of packed red cells to the RCS tube, wash red
cells 3 times with buffered normal saline
II. Centrifuge for 3 minutes at 4500 RPM (program 2)
III. After washing, remove the saline and add an additional 19 drops of NSS
to the tube. One must achieve a tomato-red or cherry red color.
d. Transfer 2 drops of anti-sera to their corresponding labeled tubes
e. Transfer 1 drop each of RCS to the tubes with anti-sera
f. Centrifuge all 5 tubes for 3 minutes at 4500 RPM (program 1)
g. Grade the agglutination (grading references is attached on the wall)
6. Test Results and Logbook
a. Test Results (Printed)
I. Print 1 copy of screening test results, following color designated per
blood type
Note:
o Labelling and expiration date
Serial Number Blood Component Expiration Date
LH-22XX-XXXX Packed Red Blood Cell 35 days
LH-22XX-XXXX-1 Fresh Frozen Plasma 1 year/ 7 years
LH-22XX-XXXX-2 Platelet Concentrate 5 days

o FFP and PC screening test results are only printed for component
preparation of blood units. If a blood unit is NOT due for
component preparation, only print out PRBC TTI screening test
result.
b. Reactive blood units
o If there's a reactive blood, please refer to staff. Do not discard
I. Obtain a segment from the reactive blood unit.
II. Repeat TTI using new sample
III. Place sample in conical tube and refer to RITM, include a segment from
the blood bag.
o Triple package the reactive samples.
o Proper labelling

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LHMRH Blood Bank (2022)
i. Infectious/Reactive Category X
Category A – Human/Animal sample once exposed to may
lead to permanent paralysis
Category B – UN3373
Category C
ii. To: Head of NRL
iii. Responsible Person: Irene Y. Baltan/0930
c. Logbooks
I. ABO/Rh typing logbook
II. TTI results logbook
III. Stored and dispensed logbook
7. Verification of Results
a. Call the staff on duty to check results and verify accordingly
8. Filing & Storage of Samples
a. After staff have signed and verified, file necessary documents in its designated
folder and rack
I. Folder for DHQ
II. TTI results (file according to blood component)
b. Store the EDTA tube of the donor under ‘Day 1’ inside the refrigerator found
along the hallway
c. Dispose other tubes into their corresponding containers with bleach solutions

B. COMPONENT PREPARATION
1. TTI Screening
a. Perform TTI screening and validation for the blood unit’s blood type
b. Blood collected in Single Bags, or Whole blood units should be labeled as PRBC,
not Whole Blood, since they are released as manually packed PRBC.
2. Light Spin (Platelet-Rich Plasma)
a. Make sure the satellite bags are properly labeled using a ballpoint pen. One for
platelet concentrate (PC) and one for fresh frozen plasma (FFP).
b. After an hour of standing, Centrifuge the whole blood (light spin – program 1).
➥ Use a balancer when necessary. When balancing, there should only be at
most 0.1 gram weight difference between the ones to be centrifuged.
➥ The light spin is Program 1 in the centrifuge. Select program 1 which has
an rpm of 2000 for 4 minutes.
c. Place a hemostat in the main tube and to the tube going to the FFP satellite bag.
d. Break the cliktip and then unlock/open the hemostat near the main bag.
e. Release the plasma separator to transfer the Platelet-rich plasma (PRP) into the
PC satellite bag until about an inch of plasma is left in the PRBC bag then
lock/close the hemostat near the main bag after.
f. Separate the PRBC bag from the satellite bags using the sealer.
g. Create a segment to be used for reverse typing (in case the blood component is
already needed).
h. Label the packed red cell properly (LH-22XX-XXXX), let it rest for 1 hour, and
store in the blood bank refrigerator afterwards.
3. Hard Spin (Platelet-Poor Plasma)
a. Take note of the weight of the PRP bag. The weight of the PRP bag minus 70 g
shall be the weight of the FFP bag after separation of the supernatant.
b. Centrifuge PRP bag (heavy spin – program 2). Don’t forget to balance.
➥From progran 1, change it to program 2 by rotating the multi-function
speed adjuster. Program 2 has an rpm of 5000 for 8 minutes.

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LHMRH Blood Bank (2022)
c. Place the centrifuged PRP in the plasma separator and the FFP bag on the
weighing scale.
d. Unlock/open the hemostat then release the plasma separator.
e. Transfer the supernatant into the FFP bag leaving the PC bag with
approximately 50-70 ml or 70 g. Lock/close the hemostat then seal the tubing to
separate the PC and FFP satellite bag.
f. Label the FFP bag properly (LH-22XX-XXXX-1), before freezing let it rest for 1
hr and freeze the plasma at -18°C or colder. Freezer for FFP is located near the
processing area.
- Note: When freezing, the FFP they are placed upside down, do not stand/
stack the FFP. They are stored properly (stand/ stack position) after they are
frozen.
4. Platelet Concentrate
a. Once the FFP and PC are prepared. Label properly (LH-22XX-XXXX-2) the PC
and Observe the “platelet ribbon” and “swirling phenomenon” inside the
platelet concentrate bag. It should be left stationary with the label side down at
room temperature for 1 hour.
b. Gently resuspend the platelet ribbon. Stand the PC at room temperature for
another hour.
c. Place the PC according to blood type (label side down) in the platelet
agitator/shaker after. Maintain platelet suspension for at most 5 days.
d. Inspect PC before issuance to ensure that no platelet aggregates are visible and
that it should demonstrate swirling phenomenon.
5. Test Results and Logbook, Verification of Results, and Filing and Storage of Samples
a. Refer to steps 6 to 8 on TTI screening and validation of blood unit’s blood type

C. COMPATIBILITY TESTING (CROSSMATCHING)

1. Receive Request
a. Check request forms (both blood request and compatibility request form).
● Make sure the request forms are patient informations printed not
handwritten on yellow paper and details of the patient are complete. (Units
needed, what unit, blood type, date when the unit will be needed and the
name of the requesting physician)
b. Log details in the receiving logbook
c. Inform the watcher/the nurse regarding the blood replacement (usually done by
the staff)
2. Prepare Set-up
a. Patient’s blood sample
I. May be in the hematology section or stored in the refrigerator found in
the drug testing room, or in the refrigerator labeled “Sample for possible
crossmatch”
II. Patients’ samples from the hemodialysis (HD) ward are forwarded,
unless requested for extraction
b. Donor’s Blood sample
I. Check the blood type being requested and the number of units being
requested
II. Get the frontmost TTI screening result form according to blood type
III. Look for the bag (front most from the left) from the ref, match the
serial number and obtain (a) segment/s sufficient for the procedure

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LHMRH Blood Bank (2022)
IV. In the blood request form, write:
➥ Blood unit’s serial number
➥ Collection date
➥ Expiration date
➥ Note beside the serial number if the blood is whole blood (WB)
or packed red blood cell (PRBC)
V. Transfer the blood sample from the segment/s into a tube labeled with
the serial number and date of performance
VI. Label the blood unit with a blood compatibility tag then return the blood
unit to the ref on the crossmatched units section
VII.
c. Crossmatching rack
I. Obtain labeled tubes from the rack beside the centrifuge and arrange as
(left to right): Blood sample, RCS, A, B, D, AC, BC
II. Patient’s sample in front and donor/s samples after
III. Crossmatch tubes (XM) at the back, depending on how many
blood units is/are to be crossmatched
IV. Label all front row tubes with the patient’s name and date, and the
following rows with the corresponding donor’s serial number and
date. The crossmatch tube/s is/are labelled with “XM” and the
serial number of the donor sample and the date.
d. Get reagents needed ready as well
3. Centrifuge
a. Centrifuge patient sample and donors’ samples for 3 minutes at 4500 RPM
(Program 2)
4. Crossmatching and Blood Typing
a. After centrifugation, obtain plasma/serum samples from the corresponding
samples. 2 drops for each tube.
I. Patient plasma/serum: XM tubes  A cells tube  B cells tube
II. Donor plasma: A cells tube  B cells tube
b. RCS for each row
I. Pipette a drop of the red cell into the RCS tube for each sample and mix
II. Fill up with saline ¾ of the tubes
III. Centrifuge for 3minutes at 4500 RPM (Program 2)
IV. Decant, resuspend, and centrifuge. Wash 3 times.
V. After the 3rd wash, resuspend in 19 drops of saline or as necessary to reach
a tomato-red or cherry red suspension
c. Immediate Spin (IS Phase)
I. 1 drop of Donor RCS to their corresponding XM tubes
II. Centrifuge for 1 minute at 1500 RPM (Program 1)
III. Gently resuspend after and check for agglutination
IV. Microscope check
i. Pipette a drop into a slide labeled with the serial number
ii. Focus on the microscope and let the staff check
V. If no agglutination is observed (0), proceed to the next phase
● If rouleaux formation is observed, rewash the RCS 4-5x more.
d. Thermo Phase (37°C Phase)
I. Add 2 drops of LISS to each XM tube
II. Incubate for 15 minutes at 37°C
Note: One may proceed to blood typing while waiting for the incubation
to finish
III. Centrifuge for 1 minute at 1500 RPM (Program 1)
IV. Gently resuspend and check for agglutination
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LHMRH Blood Bank (2022)
V. Microscope check
VI. If no agglutination is observed (0), proceed to the next phase
e. AHG Phase
I. Rewash the XM tubes 3 times (3 minutes each at 4500 RPM – Program 2)
II. After the 3rd wash, blot. Gently blot the tubes vertically against a
gauze/tissue to remove excess saline
III. Add 1 to 2 drops of AHG reagent. Mix then centrifuge for 1 minute at 1500
RPM (Program 1)
IV. Gently resuspend and check for agglutination
● If agglutination is still present despite rewashing the RCS, replace the
unit. For this cases, MTI should inform the staff on duty. In some cases,
agglutination is still present, autocontrol and DAT is done.
● If there are no improvements, the crossmatching sheet should contain
proper grading of agglutination. The physician of the patient will be
informed but this is usually done by the staff.
V. Microscope check
Grading chart:

5. Crossmatching Worksheet, Results, and Logbook

a. Crossmatching Worksheet
I. Fill out necessary details
II. Write under interpretation whether “compatible” or “incompatible”
III. Write under remarks “for transfusion” if it is compatible
b. Test Results (Printed Forms)
I. Blood typing and crossmatching result form (2 copies per patient – blue
paper)
II. Blood transfusion form (2 copies per unit)
i. Adult Green
ii. Pediatrics Pink
III. Charge slip
i. Usually done by the staff on duty
ii. Note at the bottom most of the white paper the charge slip
number, test done, number of blood units, date and time of
charging
c. Logbook
I. Crossmatching logbook
II. Stored and disposed logbook
6. Verification of Results
a. Let the staff on duty check the results and verify accordingly
b. Log the patient and the corresponding details in the releasing logbook (reception

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LHMRH Blood Bank (2022)
area)
7. Filing and Storage of Samples
a. File the following forms after:
• Compatibility request form (white)
• Blood request form (yellow)
• Crossmatching worksheet
b. Store patient and donor samples together with their RCS under ‘Day 1’ inside the
ref
c. Dispose other tubes into their corresponding containers with bleach solutions

D. BLOOD TYPE SPECIFIC TESTING (FOR FFP AND PC)

1. Receive Request
a. Check request forms (both component request and thawing schedule form).
● Make sure the patient informations printed not handwritten on yellow
paper and details of the patient are complete. (Units needed, what unit, blood
type, date when the unit will be needed and the name of the requesting
physician)
● For FFP: the second form should contain the schedule for thawing of FFP
requested. If schedule are not indicated ask the NOD to fill the necessary
data before receiving the request.
2. Log details in the receiving logbook
3. Inform the watcher/the nurse regarding the blood replacement (usually done by the
staff)

4. Prepare Set-up
a. Patient’s sample
I. May be in the hematology section or stored in the refrigerator found in
the drug testing room, or in the refrigerator labeled “Sample for
possible crossmatch”. Patients’ samples from the hemodialysis (HD)
ward are forwarded, unless requested for extraction.
II. Centrifuge sample for 3 minutes at 4500 RPM (Program 2)
b. Donor’s sample
I. Blood screening result form
II. In the blood request form, write:
i. Blood unit’s serial number
ii. Collection date
iii. Expiration date
c. Prepare tubes for forward and reverse typing for the patient’s sample
d. Prepare tubes for reverse typing only for donor/s’
e. Get reagents needed
3. Blood Typing
a. Perform both forward and reverse blood typing on Patient’s sample
b. Perform reverse blood typing on Donor/s’
4. Crossmatching worksheet, Results, and Logbook
a. Crossmatching Worksheet
I. Write the results of the forward and reverse typing of the patient
II. Write the results of the reverse typing for each donor’s unit
III. If the patient’s blood type match with the donor’s, write “blood type
specific” under the crossmatching results

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LHMRH Blood Bank (2022)
IV. Write under remarks “for transfusion” if it is blood type specific
b. Test Results (Printed Forms)
I. Blood typing and crossmatching result form (2 copies per patient – blue
paper)
II. Blood transfusion form (2 copies per unit)
i. Adult Green
ii. Pediatrics Pink
III. Charge slip
i. Usually done by the staff on duty
ii. Note at the bottom most of the white paper the charge slip
number, test done, number of blood units, date and time of
charging
c. Logbook
I. Crossmatching logbook
II. Stored and dispensed logbook
5. Verification of Results
a. Let the staff on duty check the results and verify accordingly
b. Log the patient and the corresponding details in the releasing logbook
(reception area)
6. Filing and Storage of Samples
a. File the following forms after:
I. Compatibility request form (white)
Note. FFP request forms are filed in a different folder for filing from
PRBC and PC
II. Blood request form (yellow)
III. Crossmatching worksheet
b. Store patient and donor samples together with their RCS under ‘Day 1’ inside
the ref
c. Dispose other tubes into their corresponding containers with bleach solutions

E. RELEASING OF BLOOD UNITS

1. Releasing Logbook
a. Look for the blue form corresponding to the patient and check the releasing
logbook
b. Check the serial number, blood type, and component needed
2. Prepare Blood Unit
a. Go to the refrigerator containing crossmatched blood units
b. Look for the blood bag with the corresponding serial number and blood type
c. Place the blood bag in a box
I. Make sure to secure the blood bag in an upright position
II. Don’t hold or grip the bottom part of the blood bag to avoid disturbance
3. Segment for Storage
a. Get a segment from the tubing of the blood bag. Preferably, get all segments.
b. Place the segment in a tube. Label the tube with the serial number and date of
releasing.
c. Place the tube inside the ref under ‘Day 1’
4. Release Plasma
a. Place the blood unit in the plasma separator
b. Prepare a gauze pad/tissue and scissors, and insert a hemostat in the tubing
c. Cut the end of the tubing

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LHMRH Blood Bank (2022)
I. Release the plasma
II. Leave at least 1 inch (approximately 2 fingers) of plasma then clip the
hemostat to stop the release of the plasma
III. Mix
d. Release the excess plasma from the tubing. Make sure that PRBC is the only
thing that remains in the tubing and there are no bubbles
5. Seal Tubing
a. Seal the tubing then discard the excess tubing together with the gauze
pad/tissue in the yellow bag
b. In the ‘crossmatched unit’ tag, write down the date and time of releasing (must
be the same as the one written down on the releasing logbook)
6. Double Check Information with Nurse
a. Double check the following information from the blood bag with the
information printed out in the green form and TTI screening result form:
I. Name of the patient
II. Hospital number
III. Birthday date
IV. Ward
V. Blood type of patient
VI. Blood component
VII. Serial number of the blood unit
VIII. Date of collection
IX. Original date of expiration
Note: This is the expiration date written after donation that is seen on the TTI screening
result and blood unit
7. Transportation Box
a. If all information corresponds with each other, place the blood bag inside the
transportation box. Triple packaging should be observed. A separate box should
be present for the unit itself. Make sure that the blood bag does not directly
touch the ice. Containers should be insulated to make sure the ice will not melt
during transport.
Note: Check if the ice would be enough during transportation. Replace the ice if it
seems otherwise.
8. Clean sink/working area after (most especially for manual packing)

Notes to Remember!
● Blood units are released ONE BY ONE!
● Manual Packing and Thawing
➲ Most blood units being released are manually packed (open system).
Therefore, the expiration for such units would be 24 hours from packing
(filled out in the green form). 24 hours also applies for FFP thawing.
Example: If one unit of PRBC is to be manually packed and released on
10/25/2022 at 10:07 pm, the expiration date of the said unit is 10/26/2022 at
10:07pm, regardless of the original expiration date written on the blood bag
label. The expiration date should be written on the blood compatibility tag
as well as the green form.
● Blood transfusion form (Green/Pink form)
➲ Leave the expiration details blank if it is manually packed (open system) or
thawed (this will be filled out handwritten once the unit is to be released)

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LHMRH Blood Bank (2022)
➲ If the blood units to be released are already prepared as PRBC (closed
system), thus don’t need to be manually packed, “N/A” should be
printed/written on the expiration date/time of the green/pink form.
● Returned and Re-issued Blood
➲ Blood units not transfused (NT) for reasons such as:
I. Patient has been discharged
II. Deemed not needed/necessary anymore
III. Reached > 72 hours from crossmatching
➲ Note in the releasing logbook and crossmatching form that the unit/s
was/were not transfused, date, time, and the nurse on duty
➲ File the transfusion forms in the 2022 Deferred Transfusion folder
➲ Blood unit is/are returned to the blood pool (placed in the front most) and
TTI form is also returned (placed at the front)
➲ Returned and re-issued blood logbook
I. Fill up the logbook from the date of return to remarks
II. Once the unit has been re-issued, update the logbook. Fill out patient
re-issued to and the date of re- issuance.

DONORS ROOM
A. INFORMATION EDUCATION CAMPAIGN (Use prepared IEC)
➥ Advantage of blood Donation
o Reduce risk of having cancer, stroke, heart and lung disease; Benefits the
donor and patient
o 3 Months interval
o 2-hour post meal
▪ Full meal
▪ Avoid fatty foods which could cause lipemic / chylous platelet
concentrate
B. PRE-DONATION
➥ Assess meal intakes (alcohol, food,
momma, cigarette)
➥ Sleep
➥ Ask for any medicine/ maintenance intake
C. DHQ
➥ Registration
➥ Interview
o Explain Transmission Transmissible
Infection (e.g Hepa B, Malaria, HIV)
D. BLEEDING
a. Before proceeding to the donor’s room, let the donor wash their both hands
(up-to the elbow level)
b. Phlebotomy Procedure
1. Let the donor lie on the donor’s chair, make sure he/she is comfortable
and give a blanket if necessary.
2. Identify the donor and introduce yourself as the phlebotomist .
3. Apply a tourniquet to check both arms of the donor in order to palpate
and select the preferred vein for phlebotomy.
4. After selection, clean the donor’s arm with 70% alcohol-iodine-70%

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LHMRH Blood Bank (2022)
alcohol. Allow proper contact time of disinfectants by letting it air-dry
do not blow.
5. Prepare materials (blood bag, gauze pad, micropore tape) while waiting
for the arm to dry.
6. Re-apply tourniquet after drying.
7. Twist the needle to uncap it, anchor the vein by holding the patient's
arm and placing a thumb BELOW the venipuncture site.
note: Make sure to inform the donor before inserting the needle.
8. Maintain the skin-to-vein technique (avoid puncturing directly the vein)
9. Open the hemostat to allow blood flow and secure the needle by placing
a micropore tape. Don’t forget to put gauze on top of the needle.
10. Mix the blood bag every after 15-30 seconds. Also, check if there is still
blood flow.
note: observe proper checking of blood flow.
11. If the blood bag is half-full you can now log the donor’s serial number
and details on the donor’s logbook and their corresponding DHQ. After
logging, label the blood bag accordingly.
note: USE ONLY BALLPOINT PEN FOR LABELING!!!
12. Give and explain the CUE (Confidential Unit Exclusion) during bleeding
and not after the donation.
13. After collecting enough blood, close the hemostat before releasing the
tourniquet and removing the needle.
14. Perform post-donation care, and during the donation always ask how
the donor is feeling.
15. Explain the benefits of blood donation and the do’s and don'ts after
donating blood.
NOTE: If a diversion pouch is present on the blood bag, collect EDTA sample (not sure if
eto dapat ang first na ififill before ang blood bag), if none, collect after stripping.
● Assign a serial number on the DHQ but do not log their names on the DONORS
LOGBOOK before the collection is done.
Blood bag Blood Unit Blood volume to log

Triple Blood Bag PRBC 250

Single bag Whole Blood (WB) 450

E. POST DONATION
a. Patient care & assessment
i. Let the donor rest for at least 15 minutes
b. Give water and snacks (placed in the cabinet or storage room)
c. Advice the donor what to avoid within 24 hours
i. Alcohol
ii. Smoking
iii. Coffee, tea or any diuretic drinks
iv. Momma
v. Heavy work load
vi. For drivers, advise them to rest for 2 hours to avoid lightheadedness
d. Let the donor ask any question if there is any
e. Thank the donor and encourage to donate after 3 months
F. FAINTING/DIZZINESS
a. Trendelenburg position– supine position, elevate lower extremities
G. BLOOD BAG STRIPPING
a. Using a blood bag stripper, strip the pilot tube 3x-5x. Mix and try to remove
the bubbles for every strip.

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LHMRH Blood Bank (2022)
b. Make sure to fill the pilot tube with blood before sealing. NOTE: If bubbles are
still present in the blood bag/ tube, discard through the needle.
c. Collect EDTA sample if none was collected from a diversion pouch. Observe
proper labelling (name of donor, LH- no, Blood type, date).
H. SEALING and LABELLING
a. Use the blood bag sealer to remove the needle.
b. Use the Segment No. as a guide
- 1 segment no = First seal
- 2 segment no = Second seal
- 2 segment no = Third Seal
c. Fix the pilot tubes at the side of the blood bag.
I. LOGBOOK AND LABELLING
a. After sealing, prepare the blood bag label tag with designed blood type and
component.
- single bag are labelled after sealing
- triple bag are labelled after component preparation but the blood bag
label tag is prepared.
b. Log who prepared the tag in the “For monitoring: Blood bag labelling
logbook”. The one who stripped the blood unit should be the one to prepare
the blood bag label tag.

OTHER RESPONSIBILITIES
A. INVENTORY OF BLOOD UNITS

1. Green/Blue scratch papers attached at the door of the

refrigerator may be used as scratch paper for counting
2. Count blood units in the refrigerator/s
➽ 1 is found inside the processing room
➽ 1 is located at the interns’ quarters (doffing area)
3. Always check if the blood unit is a whole blood or PRBC
➽ If unsure, one may check the donor’s logbook
4. Update the following:
➽ Board of Inventory (Every 7am and 4pm)
➽ Blood Inventory Statistics 2022 logbook
● Morning Duty: make use of pencil in filling the
necessary data
● Afternoon Duty: make use of pencil in finalizing
the necessary data specially number of extracted
during the day.
● Night Duty: responsible for final inventory with
ballpoint pen.

➽ NVBSP Blood Inventory (Statistics in the

computer)
I. Open NVBSP blood inventory on google
chrome
II. Select region (CAR) and hospital (LHMRH)
III. Click the “Daily Blood Inventory” tab then

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LHMRH Blood Bank (2022)
“Inventory”
IV. Fill up the reporting date and cutoff (7AM and
4PM), then proceed
V. Fill in the statistics then choose the name of
the staff on duty
VI. Submit

B. PREVENTIVE MAINTENANCE & TEMPERATURE MONITORING

PREVENTIVE MAINTENANCE

➽ Done every 7:00 AM (MTI Night Duty)

ROOM TEMPERATURE MONITORING
➽ Done every:
☑ 3:00 PM (MTI AM Duty)
☑11:00 PM (MTI PM Duty)
☑ 7:00 AM (MTI Night Duty)
REFRIGERATOR TEMPERATURE MONITORING
➽ Done every:
☑ 3:00 PM (MTI AM Duty)
☑ 11:00 PM (MTI PM Duty)
☑ 7:00 AM (MTI Night Duty)
➽ Refrigerators are found in the:
☑ 4 in the processing area
☑ 5 Along the hallway
☑ 2 inside the interns’ quarters (doffing area)
C. HOUSEKEEPING

AREAS OF RESPONSIBILITY

☑ Donor’s Room, Reception Area, and Processing Room

☑ Rest Room
☑ Alley going through the reception area
AFTER EVERY PROCEDURE
☑ Working Area
☑ Clean after TTI screening, component preparation,
crossmatching, or BT Specific Testing
☑ Wipe off any blood stain/s
☑ Switch off the light
☑ Close the centrifuge (never leave it open when not in use)
☑ Sink Area: Clean after manual packing
BEFORE EVERY END OF DUTY
☑ Wash used tubes, slides, and pipettes.
☑ Sweep and mop the floor
☑ Discard infectious wastes found at the working area to its
proper waste bin
☑ Refill gauze boxes, pipette box, and test tube rack with
labelled tubes

USAGE OF BLEACH/ZONROX and DETERGENT SOAP:

☑ Always make use of 1:10 (10%) bleach dilution for washing and add detergent powder.
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LHMRH Blood Bank (2022)
When 10% bleach is not available make use of 1 cup (containers cup) of bleach for washing
then add detergent powder
☑ ½ cup of bleach for the tubes and slides red container refill labelled as “TEST TUBES”
☑ ¼ cup of bleach for the tubes and slides for the white container labelled as “PASTEUR
PIPETTES & PIPETTE TIPS ONLY”
NOTE: always observe proper amount of bleach and detergent used per washing. FOR

DISPOSAL CONTAINERS
☑ Only use and replace the disposal containers used in the sink or washing area. •
☑ SEGREGATE WASTE PROPERLY

D. WARDING AND LAUNDRY

WARDING
Blood bank also chart results of compatibility result (blue form) only when:
1. The nurse on duty (NOD) / physician confirm that the compatibility blood unit/s will
not be used for the patient anymore.
● TO DO:
☑ Call the ward and ask for the “status” for the said patient.
☑ When the NOD confirms that the compatible blood unit will not be
transfused.
NOTE: Tell the MT on duty (MTOD) about the status.
☑ The MTOD or MTI can fill up the necessary data. Get the releasing logbook
and the 2 copies of compatibility results (blue form) and write:
- “NOT TRANSFUSED/ NT”
- Date the day it is confirmed
- Name of NOD:
- Time
☑ Get the “RETURNED and RE-ISSUED BLOOD” logbook and fill up the
necessary data.
☑ 1st copy of the compatibility result: LOG IT IN THE FOR WARDING AND
CHART THE RESULTS
☑ 2nd copy of the compatibility result: FILED IN THE COMPATIBILITY
RESULT 2022.
NOTE: when the results are printed in “scrap paper” make sure that this the
copy that will be filed in blood bank and the new paper is always for the patients
copy.

LAUNDRY
Blood bank also chart FOR LAUNDRY: Pillows, Pillowcase and Blanket are always used in the
Donors Room as per the donors need.
1. When used endorse it for laundry and log it in the laundry logbook
2. ASSIGNED TASK
● MORNING DUTY: Task to bring the other day pillows, pillowcase, and blanket
used in the laundry area.
● AFTERNOON DUTY: Task to retrieved the laundry
● NIGHT DUTY: Task to log the used pillows, pillowcase, and blanket for the day
and they are to endorse to the morning duty for them to bring it to the laundry
area
Note: Laundries are only brought in the morning since it is the schedule time
for washing and when the laundries are brought in the afternoon it will not be
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LHMRH Blood Bank (2022)
washed.

DAILY GENERAL ENDORSEMENT

MORNING DUTIES RESPONSIBILITIES
PLEASE CHECK IF YOU'RE DONE WITH:
☑ Housekeeping
● Reception Area.
● Component Preparation Area
● Donors Room
➺ Disinfect donors' bleeding room every after donor.
➺ Refill applicator sticks, cotton, gauze, lancets, and alcohol as needed
➺ Waste disposal
● Processing Area
○ Wash and refill used test tubes, slides, and Pasteur Pipettes
○ Refill test tubes, slides, Pasteur Pipettes, pipette tips
☑ Temperature monitoring at 3:00 PM
☑ Blood Statistics and Blood Inventory at 4:00 PM
● Record on NVBSP site, Whiteboard, and 'Blood Inventory Statistics' Logbook
☑ Test tube, Slides, and Pasteur Pipettes Retrieval from main laboratory autoclave (as
endorsed)
☑ Storage of blood samples
● Blood typing RCS
● Segments of released blood units
● TTI samples

AFTERNOON DUTIES RESPONSIBILITIES

PLEASE CHECK IF YOU'RE DONE WITH:
☑ Housekeeping
● Reception Area.
● Component Preparation Area
● Donors Room
➺ Disinfect donors' bleeding room every after donor.
➺ Refill applicator sticks, cotton, gauze, lancets, and alcohol as needed
➺ Waste disposal
● Processing Area
○ Wash and refill used test tubes, slides, and Pasteur Pipettes
○ Refill test tubes, slides, Pasteur Pipettes, pipette tips
○ Restroom and Outside Alley
☑ Temperature monitoring at 11:00 PM
☑ Fill the extracted and prepared blood in the Blood Statistics and Blood Inventory Logbook
☑ Test tube, Slides, and Pasteur Pipettes retrieval from main laboratory autoclave (as
endorsed)
☑ Storage of blood samples
● Blood typing RCS
● Segments of released blood units
● TTI samples
☑ Always update the pending list for releasing unit (write and place on the reception area)
☑ Retrieved the endorsed pillows, pillowcase, and blankets in the laundry area before 5pm.
Bring the logbook.
☑ Disposed and soaked DAY 8 specimens

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LHMRH Blood Bank (2022)
● Dispose and soak DAY 8 specimens: remove the
sticker and label of the test tubes (EDTA). Then
separate the caps from the tubes.
● soaking and endorsing it to night duty for washing.
● For EDTA caps, separate the rubber stopper from the
lavender caps. Dispose the lavender caps while the
rubber stoppers should be washed.
☑ ROTATION OF TRAYS: Move the trays 1 day forward and
put a new tray on Day 1.

NIGHT DUTIES RESPONSIBILITIES

☑ Quality control for Blood Typing Antisera, LISS, AHG reagent and Hemocue.
● Hemocue: Check if the battery are charged.
● Log the results in the Quality Control Logbook and let the staff on duty sign.
☑ Prepare a new set of “A” cells and “B” cells. Let the staff
check the RCS, log the results of the new RCS in the
Quality Control Logbook and Let the staff sign. .
☑ If there are expired PRBC units and lipemic FFP units, log
on the Registry of Expired and Disposed Logbook. With
the permission of the staff-on-duty, discard these units in
the sink. If there are expired platelet concentrate, culture
the unit with guidance of the staff, and also log in the
quality control logbook.
NOTE: Lipemic FFP units are still logged on FFP and PC
Logbook found at the reception area.
☑ Washed the soak tubes from Day 8 tray. Double check if
the trays are moved, the trays 1 day forward and a new
tray on Day 1 is present.
● Caps and rubber stopper should be completely dried
before storing and disposing.
● For the rubber stoppers and washed empty bottle of reagents, should be dried
completely before it is store in the cabinet below the agitator.
● Pasteur pipettes are dried and placed above the autoclave (main lab). Then, retrieved
the dried pasteur pipettes and store it in the processing area.
● Let the staff on duty sign the stored and disposed logbook.
☑ Mop the floor, wash and replace the hand towels in the processing, donor’s room, and
wipe the counter tops of every working area. From the reception to the processing room.
☑ Collect the trash from the bins in front of the door of the donor’s room, the paper trash
bin near the computer, and bring the trash to the hospital’s waste disposal facility located
near the morgue. Afterwhich, garbage bags should be replaced immediately with their
proper color.
☑ Always update the pending list for releasing unit (write and place on the reception area)
☑ Bring the used pillows, pillowcase, foot rugs and blankets to the laundry area. Make sure
it is log in the logbook.
☑ Preventive Maintenance and Temperature monitoring at 7:00 AM
☑ Blood Statistics and Blood Inventory at 7:00 AM
● Record on NVBSP site, Whiteboard, and 'Blood Inventory Statistics' Logbook

REFERENCES:

JIMENEZ, M.C.; JIMENEZ, S.P.; & JOSE, R.K. Blood bank endorsement: Processing Room.
LIKIGAN, April Gail B.; LUBANGAS, Grail D.; & LUMAGUE, Geline Janah C.(2022).
Blood bank endorsement: Processing Room
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RECEIVED BY:

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