Intended for healthcare professionals

Feature Shared Decision Making

Can doctors reduce harmful medical overuse worldwide?

BMJ 2014; 349 doi: (Published 03 July 2014) Cite this as: BMJ 2014;349:g4289

Transfusing Wisely

It is very encouraging to see wide-ranging campaigns to reduce medical excess such as Choosing Wisely and Too Much Medicine. Liberal transfusion of blood products is a practice in which benefit is often overemphasised and risks are underestimated. Initiatives to reduce inappropriate usage of blood products such as Better Blood Transfusion have contributed to significant improvement, such as a reduction in red cell usage of over 20% in England over the last 15 years, but substantial variation in practice and over-transfusion persists. (1,2)

We hope that existing initiatives to further improve appropriate blood usage will act synergistically with cross-specialty campaigns such as Too Much Medicine. Based on the five key questions of Choosing Wisely, the AABB, formerly the American Association of Blood Banks, has released five key recommendations: ‘Don’t transfuse more units of blood than absolutely necessary’; ‘Don’t transfuse red blood cells for iron deficiency without haemodynamic instability’; ‘Don’t routinely use blood products to reverse warfarin’; ‘Don’t perform serial blood counts on clinically stable patients’; ‘Don’t transfuse O negative blood except to O negative patients and in emergencies for women of child bearing potential with unknown blood group’. (3,4) They are intended to prompt clinicians to rethink their engrained culture of liberal transfusion practice and prompt patients to question why they are being prescribed blood.

Established liberal transfusion practice is difficult to change, even with a strong evidence base for restrictive approaches. However, with the momentum of the cultural shift that Choosing Wisely seeks to catalyse, we hope that the five “don’ts” will help patients and clinicians to drive a more evidence based approach to the use of blood products with a reduction in patient harm from over-transfusion and a reduction in hospital costs.

1. NHS Blood and Transplant. National comparative audit of blood transfusion.
2. Murphy MF, Waters JH, Wood EM & Yazer MH Transfusing blood safely and appropriately. BMJ 2013; 347:29-33.
3. Choosing Wisely. American Association of Blood Banks.
4. Callum JL, Waters J, Shaz B, Sloan S, & Murphy MF. The AABB recommendations for the Choosing Wisely Campaign of the American Board of Internal Medicine. Transfusion (in press).

Competing interests: No competing interests

11 July 2014
Stephen P Hibbs
Academic Foundation Doctor
Michael F Murphy
John Radcliffe Hospital
NHS Blood and Transplant, John Radcliffe Hospital, Oxford, OX3 9DU