Abstract
Background
Blood transfusions save millions of lives, but errors in the transfusion process can lead to serious adverse outcomes. There is a need to deliver this service using safe technologies and robust quality systems. In Palestine, the political situation requires full readiness for any emergency and attention to the availability of safe and sufficient blood units. The purpose of this study was to assess blood transfusion services (BTSs) throughout the West Bank, Palestine, to identify key gaps, pinpoint areas of strength, and direct timely enhancements to the safety and quality of the blood supply chain.
Methods
This cross-sectional study surveyed 28 blood banks from both the governmental and nongovernmental sectors of the West Bank, Palestine. We evaluated seven key areas: staffing, activity operations, quality control of equipment and reagents, blood unit handling procedures, the setting of blood donation, personnel training, and data management. An overall mean percent score for BTS was calculated.
Results
The study showed strong performance in fundamental immunohaematology-related procedures, with ABO grouping and crossmatching nearly universal (> 89%). Equipment maintenance was excellent, with all centers reporting scheduled preventive maintenance and uninterruptible power supply availability, and staff-related indicators were strong, with an overall personnel score of 87.8%. Nevertheless, important gaps were observed in advanced testing, and quality assurance phenotyping was available in only 17.9% of the centers, extended antibody identification in 32.1%, and limited participation in international proficiency testing (10.7%). Similarly, only 53.6% of centers carried out routine quality monitoring of blood products (such as platelet counts and PRBC hematocrit) and patient education. A significant difference was in the use of blood bank information systems (100% governmental vs. 57.1% nongovernmental, p = 0.016). Overall, performance was largely similar between governmental and nongovernmental sectors, with no statistically significant differences in the majority of indicators.
Conclusions
The findings indicate that although governmental and nongovernmental blood banks operate at similar levels in most routine activities, important gaps remain in advanced immunohaematology testing and external quality assurance programs. These gaps may affect transfusion safety, particularly for patients who require repeated transfusions or complex compatibility testing. Strengthening external quality assurance participation, improving access to advanced testing, and expanding electronic data management systems should be considered priority areas for improving blood transfusion services in the West Bank.
Clinical trial number
Not applicable.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12913-026-14840-4.
Keywords: Blood transfusion services, Blood bank, Quality assurance, West Bank, Palestine, Health services evaluation, Immunohematology
Introduction
Modern healthcare relies heavily on blood transfusion services to treat hematological diseases, trauma, surgical procedures, and obstetric emergencies [1]. From donor selection to patient administration, the transfusion process involves fundamental risks that call for strict safety procedures and a comprehensive risk‒benefit analysis for every operation [2].
Technical expertise and strict quality control are the cornerstones of safe transfusion treatment. To guarantee quality and safety, laboratories must rely on comprehensive testing, highly skilled personnel, and robust quality systems that adhere to international standards [3, 4]. This means implementing thorough quality assurance (QA) procedures, conducting regular internal audits, and taking part in external proficiency testing programs [5, 6]. Competency reviews, continuous staff training, and adherence to established procedures are crucial for minimizing human error and maintaining consistent service quality. Blood transfusion services (BTSs) face particular organizational structures and difficulties in the Palestinian healthcare system. Thirty-two transfusion facilities run by government, corporate, and nonprofit organizations can be found on the West Bank [7]. Despite the Ministry of Health oversight, the absence of national donor recruitment efforts, organized staff development programs, and comprehensive legislation—particularly those pertaining to transfusion safety—hinders service uniformity and quality improvement [7]. The sustainability and quality of transfusion medicine are further threatened by ongoing political and economic instability, which is marked by frequent crises and resource limitations [8, 9]. A thorough, multidomain assessment of the performance of the Palestinian BTS has not yet been carried out, although its structure has been previously defined [7]. The primary goals of this study were to (1) conduct the first thorough assessment of Palestinian blood banks by evaluating their technical capabilities, physical infrastructure, human resources, and quality management practices and (2) use the findings to identify systemic weaknesses and strengths, thereby providing an evidence base to direct the development of focused strategies for enhancing the safety and effectiveness of the country’s blood transfusion service.
Methods
Population, study design, and setting
The total number of blood transfusion services provided by governmental and nongovernmental sectors throughout the West Bank is 32 institutions. We conducted a descriptive, cross-sectional survey between March and September of 2025. Fourteen governmental and fourteen nongovernmental blood banks were selected to ensure balanced participation. The chosen blood banks were from three main regions (south, center, and north) to ensure that the results were more representative of the entire West Bank. The assessment was based on the World Health Organization’s (WHO) safe blood transfusion guidelines. Table 1 illustrates the geographic distribution of the participating blood banks.
Table 1.
Geographic distribution of participating blood banks in the West Bank (2025)
| Region | City | Governmental Centers (n) | Non-Governmental Centers (n) | Total Centers (n) |
|---|---|---|---|---|
| South West Bank | Hebron | 4 | 4 | 8 |
| Bethlehem | 1 | 1 | 2 | |
| Subtotal | 5 | 5 | 10 | |
| Mid-West Bank | Ramallah | 1 | 1 | 2 |
| Jericho | 1 | 0 | 1 | |
| Subtotal | 2 | 1 | 3 | |
| North West Bank | Jenin | 2 | 1 | 3 |
| Tubas | 1 | 0 | 1 | |
| Tulkarm | 1 | 1 | 2 | |
| Nablus | 2 | 4 | 6 | |
| Salfit | 1 | 0 | 1 | |
| Qalqiliya | 1 | 1 | 2 | |
| Subtotal | 7 | 8 | 15 | |
| Total | 14 | 14 | 28 |
Data collection and methods of evaluation
Data were collected through structured interviews with blood bank directors or designated senior staff using a semi-structured questionnaire. The questionnaire covered seven key domains: (1) staffing, including the number and qualifications of personnel; (2) blood bank operations, including blood grouping, infectious disease screening, blood donation facilities, and component preparation; (3) equipment and reagents, with emphasis on quality control, maintenance, and calibration; (4) procedural adherence, including SOPs and blood product quality checks; (5) donor management, including confidential donor interviews and safety procedures; (6) staff management, including performance assessment, safety, and training; and (7) data management, including record keeping and backup plans for system malfunctions. Because the information was collected mainly through interviews, many of the assessed indicators were based on self-reported information rather than independent on-site audits or direct observation. Although responses were clarified during the interviews when needed, the possibility of reporting bias cannot be excluded.
The data collection instrument was developed specifically for this study based on international guidelines and standards for blood transfusion services, including the World Health Organization quality management system for blood transfusion services, the American Association of Blood Banks (AABB) standards for blood banks and transfusion services, and quality indicators recommended by the International Society of Blood Transfusion and the European Directorate for the Quality of Medicines & HealthCare [10–19]. These guidelines recommend evaluation of key domains including staffing and personnel qualifications, operational activities and testing capabilities, equipment and reagent quality assurance, procedural adherence and blood component quality control, donor-related processes and safety measures, staff training and safety protocols, and data management systems. Accordingly, the questionnaire was designed to cover these domains. The English version of the instrument is provided in Additional file 1.
Scoring system
A composite score was calculated for each major section (e.g., equipment, reagents & testing, procedures, etc.) to summarize the overall performance. The score was calculated mathematically as follows:
For each section, every “Yes” response to a quality indicator was assigned 1 point, and every “No” response was assigned 0 points. The total points earned by a blood bank in a section were summed. To obtain a percentage score, this total was then divided by the total number of indicators in that area and multiplied by 100.
Ethical approval
Our research was authorized by An-Najah National University’s Institutional Review Board (IRB) (Ref: Mas. Oct. 2023/39). For governmental blood banks, the necessary approvals were obtained from the Palestinian Ministry of Health, while participating nongovernmental blood banks provided their direct consent. All participants provided informed consent, and the confidentiality of both the blood bank directors and their institutions was assured.
Statistical analysis
Data were entered and analyzed using the Statistical Package for Social Sciences (IBM-SPSS), version 20. Categorical variables are presented as frequencies and percentages. The overall performance scores were converted into mean percentage scores, which were calculated by dividing the total score obtained for each index by the total number of indicators in that index. A chi-square test was used to compare the number of male and female staff in shared blood centers. In addition, Fisher’s exact test was used to compare governmental and nongovernmental blood banks in terms of all quality indicators at the p < 0.05 level or threshold.
Validation of the survey
Prior to full data collection, the survey was pilot tested onsite at five blood banks located within the West Bank. Because the total number of blood banks in the West Bank was limited, it was not feasible to conduct the pilot outside the target setting. The purpose of the pilot was to assess the clarity, acceptability, flow, and internal consistency of the questionnaire, rather than to evaluate institutional performance or provide corrective feedback. Minor wording and formatting changes were made after the pilot to improve clarity. If any of the pilot-tested centers were later included in the final survey, this may have introduced a limited degree of familiarity with the instrument; however, no training, performance feedback, or quality-improvement intervention was provided before the final assessment. The pilot study’s Cronbach’s alpha was 0.74, indicating acceptable internal consistency.
Results
This evaluation of 28 blood transfusion services in the West Bank indicates a system with strong foundational infrastructure and generally similar performance across governmental and nongovernmental sectors, as well as limitations in advanced testing and active quality assurance.
The backbone of these services consists of 192 professionals; the majority (55.2%) are women and have a strong educational background, and 72.9% have a Bachelor of Science degree or higher (Table 2).
Table 2.
Composition and qualifications of the blood bank workforce in the West Bank, Palestine (2025)
| Academic Qualification | Male n (%) | Female n (%) | Total n (%) |
|---|---|---|---|
| PhD | 1 (0.5%) | 0 (0.0%) | 1 (0.5%) |
| MSc | 20 (10.4%) | 20 (10.4%) | 40 (20.8%) |
| BSc | 57 (29.7%) | 83 (43.2%) | 140 (72.9%) |
| Associate Degree | 8 (4.2%) | 3 (1.6%) | 11 (5.7%) |
| Total | 86 (44.8%) | 106 (55.2%) | 192 (100%) |
The assessment of service capabilities clearly distinguished between routine and advanced testing. Basic activities such as blood sampling (89.3%), basic grouping (89.3–100%), and cross-matching (100%) were nearly universal. However, only 32.1% of facilities offered antibody identification, and only 17.9% offered red-cell phenotyping, indicating a significant lack of advanced immunohaematology testing (Table 3).
Table 3.
Operational activities and testing capabilities of blood banks in the West Bank (2025)
| Category | Activity | Type of blood bank | p value | Total Yes, n (%) | Total No, n (%) | |
|---|---|---|---|---|---|---|
| Governmental (n = 14) Yes, n | Non-Governmental (n = 14) Yes, n | |||||
| Donor Phlebotomy | Blood unit collection | 13 | 12 | > 0.999 | 25 (89.3) | 3 (10.7) |
| Blood Grouping | Forward grouping | 14 | 14 | NA | 28 (100.0) | 0 (0.0) |
| Reverse grouping | 14 | 11 | 0.222 | 25 (89.3) | 3 (10.7) | |
| D weak (Du) testing | 14 | 13 | 0.222 | 27 (96.4) | 1 (3.6) | |
| Pretransfusion tests designed to ensure blood compatibility | Crossmatch | 14 | 14 | NA | 28 (100.0) | 0 (0.0) |
| DAT/IAT | 14 | 13 | > 0.999 | 27 (96.4) | 1 (3.6) | |
| Antibody screen (recipients) | 8 | 7 | > 0.999 | 15 (53.6) | 13 (46.4) | |
| Antibody screen (donated units) | 0 | 4 | 0.098 | 4 (14.3) | 24 (85.7) | |
| Antibody identification | 5 | 4 | > 0.999 | 9 (32.1) | 19 (67.9) | |
| Antibody titration | 4 | 4 | NA | 8 (28.6) | 20 (71.4) | |
| Phenotyping | 3 | 2 | > 0.999 | 5 (17.9) | 23 (82.1) | |
| 3.Component Preparation | Whole blood | 3 | 2 | > 0.999 | 5 (17.9) | 23 (82.1) |
| PRBCs | 13 | 12 | > 0.999 | 25 (89.3) | 3 (10.7) | |
| FFP | 8 | 10 | 0.695 | 18 (64.3) | 10 (35.7) | |
| Platelets | 8 | 8 | > 0.999 | 16 (57.1) | 12 (42.9) | |
| Cryoprecipitate | 6 | 6 | > 0.999 | 12 (42.9) | 16 (57.1) | |
| 4. Screening for Infectious Disease | Screening for infectious diseases | 12 | 13 | > 0.999 | 25 (89.3) | 3 (10.7) |
| Rapid tests | 4 | 4 | > 0.999 | 8 (28.6) | 20 (71.4) | |
| 5.Special Procedures | Apheresis | 1 | 3 | 0.596 | 4 (14.3) | 24 (85.7) |
NA: No statistics are computed because a variable is a constant in both groups
Blood component preparation was more common for packed red blood cells (89.3%) than for platelet concentrates (57.1%). Importantly, there were no statistically significant differences in any of these operational tasks between governmental and nongovernmental blood banks (Table 3).
This contrast between strong basic services and deficiencies in advanced practices was also evident in quality assurance systems. Equipment and infrastructure maintenance were excellent, with excellent scores for preventive maintenance and emergency power (Table 4).
Table 4.
Quality assurance indicators for equipment, reagents, and testing
| Category | Quality Assurance Indicator | Type of blood bank | p value | Yes (%) | No (%) | |
|---|---|---|---|---|---|---|
| Governmental (n = 14) Yes, n | Non-Governmental (n = 14) Yes, n | |||||
| Equipment | Periodic calibration for all equipment | 13 | 12 | > 0.999 | 89.3% | 10.7% |
| Availability of operating instructions (manuals) | 14 | 14 | NA | 100% | 0% | |
| Scheduled preventive maintenance | 14 | 14 | NA | 100% | 0% | |
| Availability of backup instruments | 12 | 12 | > 0.999 | 85.7% | 14.3% | |
| Recording temperature of refrigerators | 13 | 14 | > 0.999 | 96.4% | 3.6% | |
| Recording temperature of freezers | 14 | 12 | 0.481 | 92.9% | 7.1% | |
| Uninterruptible power supply (UPS) for all equipment | 14 | 14 | NA | 100% | 0% | |
| Regular pipette accuracy & reproducibility checks | 12 | 12 | > 0.999 | 85.7% | 14.3% | |
| Overall Equipment QA Score | 93.8% | 6.3% | ||||
| Reagents & Testing | Inventory Control | 14 | 13 | > 0.999 | 96.4% | 3.6% |
| Records for reagent receipt, use, and disposition | 13 | 13 | > 0.999 | 92.9% | 7.1% | |
| Assessment of new reagent performance | 13 | 10 | 0.326 | 82.1% | 17.9% | |
| Internal QC for immunohematology and serology | 12 | 13 | > 0.999 | 89.3% | 10.7% | |
| Participation in international proficiency testing | 0 | 3 | 0.222 | 10.7% | 89.3% | |
| Written corrective action for out-of-range QC | 11 | 11 | > 0.999 | 78.6% | 21.4% | |
| Overall Reagent & Testing QA Score | 75.0% | 25.0% | ||||
NA: No statistics are computed because a variable is a constant in both groups
However, external quality assurance was virtually nonexistent. Only 10.7% of the centers participated in international proficiency testing (Table 4).
Additionally, regular quality testing of blood components was not performed. Only 53.6% of facilities regularly measured platelet counts or PRBC haematocrits, donor education was a weakness, and equipment was not available in almost half of the facilities (Table 5).
Table 5.
Quality assurance indicators for procedures, blood components, and donation areas
| Category | Quality Assurance Indicator | Type of blood bank | p value | Total Yes, (%) | Total No, (%) | |
|---|---|---|---|---|---|---|
| Governmental (n = 14) Yes, n | Non-Governmental (n = 14) Yes, n | |||||
| Procedural Adherence and Blood Component Quality Control | Presence of (SOPs) | 14 | 12 | 0.481 | 92.9% | 7.1% |
| Maintain appropriate temperature during distribution/transport | 14 | 14 | NA | 100% | 0% | |
| Sterility of blood units checked regularly | 14 | 9 | 0.041 | 82.1% | 17.9% | |
| Platelet count measured regularly | 8 | 7 | > 0.999 | 53.6% | 46.4% | |
| PRBC hematocrit measured regularly | 8 | 7 | > 0.999 | 53.6% | 46.4% | |
| Have SOPs for waste management and disposal | 14 | 13 | > 0.999 | 92.9% | 7.1% | |
| Overall Procedure & Blood Units Score | 79.2% | 20.8% | ||||
| Donor-Centric Processes and Safety Measures | Donor interview/eligibility conducted confidentially | 13 | 12 | > 0.999 | 89.3% | 10.7% |
| Area equipped for initial treatment of adverse reactions | 10 | 10 | > 0.999 | 71.4% | 28.6% | |
| Sterile system for collection and processing | 13 | 12 | > 0.999 | 89.3% | 10.7% | |
| Having a rejection policy for donation | 13 | 10 | 0.326 | 82.1% | 17.9% | |
| Having educational materials for donors | 8 | 7 | > 0.999 | 53.6% | 46.4% | |
| Overall Blood Donation Area Score 77.1% | ||||||
NA: No statistics are computed because a variable is a constant in both groups
Human resources and safety protocols were generally well developed, with widespread use of personal protective equipment (100%) and a high degree of staff certification (78.6%), which contributed to the high overall staff score of 87.8% (Table 6). No significant differences were found between the two departments in these areas. A notable exception to this rule of uniformity is data management.
Table 6.
Staff management, training, and safety protocols
| Quality Assurance Indicator | Type of blood bank | p value | Total Yes, (%) | Total No, (%) | |
|---|---|---|---|---|---|
| Governmental (n = 14) Yes, n | Non-Governmental (n = 14) Yes, n | ||||
| Training & Development | |||||
| Receiving initial and continued training per SOP | 11 | 10 | > 0.999 | 75.0% | 25.0% |
| Receiving regular biosafety and preventive action training | 12 | 12 | > 0.999 | 85.7% | 14.3% |
| Safety & Policy | |||||
| Wearing personal protective equipment (PPE) | 14 | 14 | NA | 100% | 0% |
| Have written record for incidents and complaints | 14 | 11 | 0.222 | 89.3% | 10.7% |
| Having a postexposure policy | 14 | 12 | 0.481 | 92.9% | 7.1% |
| Performance & Competency | |||||
| Having an annual performance assessment for each employee | 11 | 11 | > 0.999 | 78.6% | 21.4% |
| Regular assessment of personnel competency | 13 | 13 | > 0.999 | 92.9% | 7.1% |
| Overall Personnel & Organization QA Score | 87.8% | 12.2% | |||
The blood bank information system (BBIS) implementation rate was significantly higher for government blood banks (100%) than for nongovernment blood banks (57.1%) (p = 0.016) (Table 7). Additionally, 21.4% of all centers relied completely on paper records, and 22.7% of centers using blood bank information systems lacked downtime protocols, indicating insufficient digital transformation. (Table 7).
Table 7.
Data management systems and contingency planning in blood banks
| Data Management Status | Type of blood bank | p value | Number of Centers | Percentage | Key Findings & Gaps | |
|---|---|---|---|---|---|---|
| Governmental (n = 14) Yes, n | Non-Governmental (n = 14) Yes, n | |||||
| Using a Blood Bank Information System | 14 | 8 | 0.016 | 22 | 78.6% | |
| With a downtime procedure | 10 | 7 | 17 | (77.3% of digital users) | Gap: 22.7% lack a contingency plan for system failures. | |
| Without a downtime procedure | 4 | 1 | 5 | (22.7% of digital users) | ||
| Using Paper-Based Records Only | 0 | 6 | 6 | 21.4% | ||
| Record Retention Periods | 0 | 6 | 6 | (100% of paper users) | Gap: Reliance on manual systems with variable archiving (1–10 years). | |
Discussion
This study aimed to evaluate blood transfusion services in the West Bank by assessing their technical capabilities, physical infrastructure, human resources, quality assurance practices, donor-related processes, and data management systems. Overall, the findings show that blood transfusion services have a strong foundation for routine transfusion activities. Most centers reported performing essential procedures such as ABO grouping, crossmatching, infectious disease screening, and equipment maintenance. The workforce also showed a generally strong educational profile, and staff safety procedures were widely implemented. However, important gaps were identified in advanced immunohaematology testing, routine blood component quality control, participation in external quality assurance programs, donor education, and electronic data management. This contrast suggests that the system is generally able to support routine transfusion needs but may face difficulties when managing complex compatibility testing, repeatedly transfused patients, or quality assurance requirements that depend on advanced laboratory capacity and external benchmarking.
Several strengths were identified in the current system. Blood component preparation is widely implemented, infectious disease screening is performed in most centers, and equipment maintenance practices are generally well established. These findings suggest that basic transfusion practices are functioning at an acceptable level in most blood banks. The relatively high educational level of staff is also an important strength, as most personnel hold at least a bachelor’s degree. Similar findings have been reported in other middle-income countries, where qualified laboratory personnel support the implementation of routine transfusion procedures [9, 20].
Although most staff had a good educational background, advanced immunohaematology testing was not widely available. This suggests that the main limitation may not be staff education itself, but rather limited access to specialized training programs, equipment, and reagents. In many low-resource settings, staff receive adequate basic training but have limited opportunities for advanced training in areas such as antibody identification and phenotyping. Therefore, improving continuing professional training programs and access to specialized training may help improve transfusion services. This is a typical problem in environments with limited resources, where initial training might be sufficient but access to specialized and further education is limited [3]. The high personnel score (87.8%) should therefore be interpreted cautiously, as annual performance assessments may not fully capture proficiency in advanced immunohaematology methods. This disparity may reflect a system-level limitation in which routine performance indicators do not fully capture advanced technical competence.
There is no one cause for the extremely low performance in international proficiency testing (10.7%), antibody identification (32.1%), and phenotyping (17.9%). Instead, it is the outcome of a number of interconnected obstacles that are frequently seen in weak health systems.
One possible explanation is the financial cost of advanced equipment and reagents, which may limit the ability of some blood banks to implement advanced immunohaematology testing. Because of Palestine’s political and economic unrest, it is difficult to obtain automated systems and expensive advanced immunohaematology reagents [7, 9]. This is in line with research from other low-resource contexts, where a significant obstacle to deploying advanced transfusion services is the high cost of reagents and equipment [21]. However, in fragile and resource-constrained settings, the performance of blood transfusion services is shaped not only by the availability of laboratory equipment, but also by wider health-system conditions. Safe and adequate blood supply is considered an essential component of health-system infrastructure, and emergency preparedness requires planning to maintain safe blood supply during disruptions [11, 22]. Political and economic instability can affect continuity of reagent supply, preventive maintenance, staff training, donor recruitment, transport of blood units, referral of complex samples, and participation in external quality assurance programs [22, 23]. These system-level pressures are particularly relevant in the West Bank, where movement restrictions, recurrent crises, and financial constraints may interrupt routine service planning and delay the development of advanced transfusion capacity [7, 9].
The limited availability of antibody identification, red-cell phenotyping, and international proficiency testing observed in this study is therefore likely to reflect more than the cost of automated platforms or advanced immunohaematology reagents alone. It may also reflect difficulties in procurement, shipment of EQA samples, staff release for specialized training, maintaining uninterrupted supply chains, and developing national regulatory requirements for advanced quality assurance. Similar challenges have been described in other low-resource settings, where hospital-based transfusion services face constraints related to blood availability, financing, training, and systematic monitoring of transfusion delays [15, 24, 25].
This context is important for interpreting the Palestinian findings. The high coverage of basic transfusion procedures shows that the system has maintained essential service delivery despite difficult conditions. At the same time, the limited use of advanced testing and EQA indicates that service resilience remains incomplete. In conflict-affected or politically unstable settings, transfusion safety depends not only on technical capacity inside individual blood banks but also on national coordination, stable procurement pathways, contingency planning, referral networks for complex testing, and sustained investment in quality management systems [22, 23].
Reliance on a single or limited number of central sites for advanced testing may be practical in a resource-limited setting, but it also creates vulnerability. If referral pathways are interrupted by closures, transport restrictions, or emergency conditions, peripheral blood banks may have difficulty accessing advanced compatibility testing when it is most needed. Strengthening transfusion services in this context may therefore require a mixed approach: maintaining centralized reference capacity for complex testing while building minimum advanced competencies, clear referral procedures, and emergency contingency plans across peripheral centers [22, 23].
Advanced compatibility testing and participation in external quality assurance (EQA) may remain inconsistently implemented when they are not clearly required by national regulations or accreditation standards [7]. WHO guidance describes EQA as an important component of transfusion laboratory quality systems because it provides an independent assessment of laboratory performance and helps identify weaknesses requiring corrective action [24, 25]. In the absence of a regulatory requirement, blood banks with limited resources will naturally prioritize needed, basic tests over more complex, elective tests.
A similar pattern of strong basic transfusion services but limited advanced testing has been reported in other low- and middle-income settings. Similar high rates of basic transfusion-transmitted infection screening have been reported in studies from other conflict-affected and resource-constrained regions, such as parts of South Asia and Sub-Saharan Africa, but remarkably low rates of antibody screening and EQA participation have been reported [1, 26].
In the Palestinian context, logistical and political factors may also affect transfusion services. Transportation delays between cities, difficulties in importing laboratory reagents, and limited access to external training opportunities may all contribute to the limited availability of advanced testing in some centers. These factors may also affect participation in international external quality assurance programs and the development of advanced transfusion services [8, 9]. Beyond the usual financial limitations observed in other low-resource contexts, this introduces another level of complexity.
The study also showed that routine quality control testing of blood components and donor education activities were not performed in all centers. This may indicate that some blood banks focus mainly on routine clinical service delivery and may have limited resources for quality improvement activities and donor education programs. However, quality control of blood components and donor education are important parts of a safe transfusion system and should be strengthened as part of quality improvement programs. A secure blood supply is supported by the World Health Organization’s policy of voluntary, non-remunerated blood donation from low-risk donors, which may be weakened when donor education and recruitment activities are limited [11, 27]. This deficiency might result from prioritizing immediate clinical service delivery over long-term donor base growth and from a lack of resources allocated specifically for public awareness efforts.
Similarly, irregular quality tests on platelets and PRBCs point to a weakness in the internal culture of quality management. This suggests that rather than a constant check of the final product’s safety and effectiveness, quality is frequently seen as a result of process completion (e.g., having SOPs). This represents an important opportunity to reduce the release or transfusion of blood components that may not meet expected quality specifications, a concern that has been highlighted in relation to blood component quality assessment [28].
Overall, the findings suggest that blood transfusion services in the West Bank have established basic transfusion practices but still require improvement in advanced testing, external quality assurance, and data management systems. These gaps are likely related to resource limitations, training opportunities, and system organization rather than individual staff performance. Addressing these areas could improve transfusion safety and the overall quality of blood transfusion services.
Limitations of the study
This study’s interpretations are subject to several limitations. Although it provides a broad overview of blood transfusion services in the West Bank, its cross-sectional design does not allow assessment of changes in performance over time. The study also relied mainly on information reported by blood bank directors or designated senior staff rather than direct observational audits of practice. Therefore, social desirability bias, recall bias, and institutional reporting bias cannot be excluded. Another limitation is that the pilot testing was conducted within the West Bank because the study targeted a small and defined population of blood banks. Therefore, some pilot-tested centers may have been included in the final assessment. Although the pilot was limited to testing clarity and acceptability and did not involve performance feedback or corrective training, this may have introduced a small degree of familiarity with the questionnaire. The findings are limited to the West Bank and do not represent the Gaza Strip or all Palestinian transfusion services. Finally, the study assessed structures, processes, and quality indicators, but it did not directly measure clinical outcomes, transfusion reactions, near-miss events, or patient harm. Therefore, the relationship between the identified service gaps and actual clinical outcomes should be interpreted cautiously.
Conclusions
Blood transfusion services in the West Bank show good performance in basic transfusion activities, staffing, and equipment maintenance. However, important gaps remain in advanced immunohaematology testing, participation in external quality assurance programs, routine blood component quality control, donor education, and electronic data management systems. These gaps may affect transfusion safety, particularly for patients who require repeated transfusions or complex compatibility testing. Future efforts should focus on improving access to advanced testing, strengthening external quality assurance participation, expanding staff training programs, improving donor education, and enhancing digital data management and contingency planning. Addressing these areas may help improve the safety, resilience, and quality of blood transfusion services in the West Bank.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
The authors would like to thank An-Najah National University for providing the academic resources and facilities that enabled this study. Furthermore, we would like to sincerely thank the Palestinian Ministry of Health and the administrations of the participating institutions for their invaluable cooperation and for granting access to the data required for this study. The authors declare that ChatGPT (OpenAI, San Francisco, CA, USA) was used solely as an editorial support tool to assist with language refinement, readability, and consistency of the manuscript. The tool was not used to generate scientific content, perform data analysis, interpret results, or draw conclusions. All scientific content, interpretations, analyses, and final editorial decisions were made independently by the authors. The authors reviewed and approved the final manuscript and take full responsibility for its accuracy, integrity, and originality.
Abbreviations
- BTS
Blood Transfusion Services
- EQA
External Quality Assurance
- SPSS
Statistical Package for the Social Sciences
- IRB
Institutional Review Board
- BBIS
Blood Bank Information System
- PRBC
Packed Red Blood Cells
- SOPs
Standard Operating Procedures
- QA
Quality Assurance
- WHO
World Health Organization
Author contributions
The study’s conceptualization was the contribution of AA, SHZ, and WAS. Additionally, they developed the technique, planned the study, and critically evaluated and polished the report. Data collection and analysis were performed by WAS, IS, MA, MSH, MA, KA, WM, HR, SA, HM, and MAA. The project was planned by AA and SHZ, who also critically evaluated the article. Under the guidance of AA and SHZ, WAS wrote the first draft of the manuscript. The final version of the paper was examined, edited, and approved for submission by all the authors.
Funding
No particular grant from public, private, or nonprofit funding organizations was received for this study.
Data availability
The data files used and/or analysed during the current study are available from the corresponding authors upon request.
Declarations
Ethics approval and consent to participate
The An-Najah National University IRB approved the study protocol (Ref: Mas. Oct. 2023/39), and the study was conducted in compliance with the Declaration of Helsinki. Before any data were collected, administrative approval was obtained from the participating hospital. Every participant provided written informed consent. All of the information collected was anonymized via numerical codes to maintain confidentiality. These codes were only used for research purposes and were only available to the principal investigators.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data files used and/or analysed during the current study are available from the corresponding authors upon request.