American Society of Hematology

View all recommendations from this society

Released December 4, 2013

Don’t transfuse more than the minimum number of red blood cell (RBC) units necessary to relieve symptoms of anemia or to return a patient to a safe hemoglobin range (7 to 8 g/dL in stable, non-cardiac in-patients).

Transfusion of the smallest effective dose of RBCs is recommended because liberal transfusion strategies do not improve outcomes when compared to restrictive strategies. Unnecessary transfusion generates costs and exposes patients to potential adverse effects without any likelihood of benefit. Clinicians are urged to avoid the routine administration of 2 units of RBCs if 1 unit is sufficient and to use appropriate weight-based dosing of RBCs in children.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

1-5: The American Society of Hematology (ASH) Choosing Wisely® Task Force utilized a modified Delphi technique to collect suggestions from committee members and recipients of its clinically focused newsletter, the ASH Practice Update. Respondents were asked to consider the core values of harm, cost, strength of evidence, frequency and control. Fifty-nine of 167 ASH committee members (35%) and 2 recipients of the ASH Practice Update submitted 81 unique suggestions. The Task Force used a nominal group technique (NGT) to identify the top 20 items, which were scored by ASH committee and practice community members, with a 46 percent participation rate. ASH’s Task Force reviewed all scores to develop a 10-item list. A professional methodologist conducted a systematic literature review on each of the 10 items; the Task Force chair served as the second reviewer. Evidence reviews and source material for the 10 items were shared with ASH’s Task Force, which ranked the items according to the core values. The Task Force then identified the top 5 items plus 1 alternate. ASH member content experts provided external validation for the veracity and clarity of the items.

6–10: Suggestions for the second ASH Choosing Wisely list were solicited from members of the ASH Committee on Practice, the ASH Committee on Quality, the ASH Choosing Wisely Task Force, ASH Consult-a-Colleague volunteers and members of the ASH Practice Partnership. Six principles were used to prioritize items: avoiding harm to patients, producing evidence-based recommendations, considering both the cost and frequency of tests and treatments, making recommendations in the clinical purview of the hematologist, and considering the potential impact of recommendations. Harm avoidance was established as the campaign’s preeminent guiding principle. Guided by the 6 principles, the ASH Choosing Wisely Task Force scored all suggestions. Modified group technique was used to select 10 semi-finalist items. Systematic reviews of the literature were then completed for each of the 10 semi-finalist items. Guided by the 6 core principles outlined above, and by the systematic reviews of the evidence, the ASH Choosing Wisely Task Force selected 5 recommendations for inclusion in ASH’s second Choosing Wisely Campaign.

ASH’s disclosure and conflict of interest policy can be found at


Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK, Holcomb JB, Illoh O, Kaplan LJ, Katz LM, Rao SV, Roback JD, Shander A, Tobian AA, Weinstein R, Swinton McLaughlin LG, Djulbegovic B; Clinical Transfusion Medicine Committee of the AABB. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med. 2012 Jul 3;157(1):49–58.

Retter A, Wyncoll D, Pearse R, Carson D, McKechnie S, Stanworth S, Allard S, Thomas D, Walsh T; British Committee for Standards in Hematology. Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients. Br J Haematol. 2013 Feb;160(4):445–64.