Choosing Wisely® is a medical stewardship and quality improvement initiative led by the American Board of Internal Medicine (ABIM) Foundation in collaboration with leading medical societies in the United States. The Choosing Wisely® campaign challenges medical societies to identify 5 tests, procedures, or treatments within each specialty’s clinical domain that are offered to patients despite an absence of evidence demonstrating benefit or, in some cases, despite evidence demonstrating disutility or harm. The American Society of Hematology (ASH) is an active participant in the Choosing Wisely® project.

In the December 5, 2014, issue of Blood, Hicks et al. report that through a rigorous, evidence-based methodology, the ASH Choosing Wisely® Task Force has identified 5 tests and treatments that practicing hematologists should carefully consider because, in the circumstances described, the risk of harm and/or cost of the specified interventions likely outweigh the anticipated benefits [1].

The first recommendation advises against liberal transfusion of red blood cell (RBC) transfusion. “In situations where transfusion of RBCs is necessary, transfuse the minimum number of units required to relieve symptoms of anemia or to return the patient to a safe hemoglobin range (7-8  g/dL in stable, noncardiac in-patients)”, it states. The key references supporting this recommendation are two recently published practice guidelines [1, 2].

“Transfusion of the smallest effective dose of RBCs is recommended, the article explains, because, compared with restrictive strategies, liberal transfusion does not improve patient outcomes. Therefore, liberal transfusion generates costs and exposes patients to potential harms from transfusion without likelihood of benefit.” It is advised that clinicians avoid administering 2 units of RBCs if 1 unit is sufficient and that appropriate weight-based dosing of RBCs be used in children.


1. Hicks LK, Bering H, Carson KR, et al. The ASH Choosing Wisely(R) campaign: five hematologic tests and treatments to question. Blood 2013;122:3879-83. [Access free full-text article]

2. Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med 2012;157:49-58. [Access free full-text article]

3. Retter A, Wyncoll D, Pearse R, et al. Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients. Br J Haematol 2013;160:445-64. [Access free full-text article]