Many quality assurance workers have been concerned about undertransfusion since acquired immune deficiency syndrome was first shown to be transmitted by blood transfusion. Physicians may be reluctant to order transfusions, and patients may be hesitant to receive blood therapy, even in situations meeting established guidelines for transfusion therapy. Transfusion guidelines are reviewed and compared to actual practices in a tertiary care hospital. Clinical cases between the limits set by the guidelines are examined and shown not to meet the definition of undertransfusion.