Blood component transfusion is an important and lifesaving Emergency Department (ED) procedure. It is not however risk-free and careful consideration of its clinical benefit for each individual patient is therefore essential. In 2008, we audited the patterns of blood component usage in 2007 within our ED. This work revealed that whilst 3209 units of blood component were ordered only 39.5% were transfused, and 9.5% were unaccounted for. This was the first and only published detailed look at ED blood transfusion practices. We had to address our poor traceability (i.e. unaccounted for units), our high blood usage, and our ordering of units which were then not transfused as this can lead to wastage. Firstly, better links between the ED and the Scottish National Blood Transfusion Service (SNBTS) were established. A set of improvement measures were then implemented including better ED medical and nursing staff education, monthly traceability reports sent to the ED clinical management teams, the introduction of an ED transfusion guideline, moving our blood fridge into the resuscitation room, having a named ED transfusion consultant and ED transfusion link nurse, ED consultant representation on the Hospital Transfusion Group and finally increasing awareness of ED emergency transfusion with a rotational thromboelastometry (ROTEM) research programme. In 2012, we re-audited our practice looking at our blood component usage in 2011. There was a 64% reduction in blood component ordering (3209 vs. 1034 units), a 39% reduction in blood component transfusion (1131 vs. 687 units), a 68% increase in the proportion of ordered units that were transfused and a 96% reduction in unaccounted units (289 vs. 9 units) between 2007 and 2011. In attempting to cost the savings resulting from our changes we showed that SNBTS spent £306,437 less in 2011 compared to 2007 on handling and issuing ED transfusion requests. Our improvements are immediately generalizable across the UK and the potential savings to the NHS are enormous.