Once upon a time at the dawn of modern blood transfusion, the burden for obtaining blood rested with patients and their families to locate donors for specific needs such as scheduled surgery. When blood storage became feasible and the concept of blood “banking” was promulgated, the responsibility of blood procurement shifted over time from the family to the physician, then to the hospital as a shared service for its patients, and then to the local blood center for the hospitals in a community. Although some hospitals still collect blood (6.4% of US red blood cells [RBCs] in 2004),1 today we have highly evolved, interconnected regional and national networks of blood suppliers that manufacture and distribute millions of blood components under strict federal regulations and professional accreditation requirements. For the most part, these systems work well, and constant, adequate, rapid availability of blood components is easily taken for granted by patients, physicians, and the community. Mass-casualty tragedies like 9/11 stimulate blood donations as one outlet for public compassion, though sadly, blood transfusions have not been needed in large quantities in these situations.2 Events in recent years have blood bankers asking themselves, What if? What if the interlocking web of systems needed for the blood supply developed a fray in one corner which could unravel the safety net? The interdependent nature of our modern global society is apparent from the ramifications of problems in other realms such as the energy supply, terrorism, communicable diseases, and food and pharmaceutical safety. A myriad of threats could disrupt the operations of hospitals and blood banks: another terrorist attack with bioagents, cyber-disruption, or nuclear materials or an epidemic, an earthquake, or problems no one has yet considered. As blood donor recruiters rightly emphasize, acute “day-of” needs must be met with what is in hand—but what if blood supplies were insufficient or could not be replenished? A national blood reserve of stored RBCs has been considered in the United States. In this concept, up to 10,000 group O RBCs would be stockpiled in several locations for an emergency, with frequent turnover to avoid expiration. The Department of Health and Human Services’ (HHS) Advisory Committee on Blood Safety and Availability (ACBSA) recommended establishing this program in 2004.3 However, 3 years later, representatives from the AABB and America's Blood Centers told the ACBSA that a liquid RBC reserve would be difficult to fund, less preferable than walking blood donors, and less necessary with improved emergency planning.4 Another approach to blood inventory management is frozen RBCs. Hess5 reviewed the rich history of this technology. Frozen RBCs can be stored for up to 10 years by regulation and much longer in research experiments.6 Frozen RBCs were used in many US centers in the 1960s and 1970s for medical and logistical reasons and were the first leukoreduced cellular blood component—but they largely have faded away except in the American Rare Donor Program. However, the US Department of Defense (DoD) retained its longtime interest in development and application for military support, and as of 2002 had more than 50,000 frozen RBC units placed around the world.7 Haemonetics Corp. obtained clearance from the Food and Drug Administration (FDA) in 2001 for its closed system to permit 14-day storage after thawing, and subsequently the system was cleared for RBCs stored in additive solutions.8 In this issue of TRANSFUSION, Erickson and colleagues9 describe the emergency blood management plan at Yale–New Haven Hospital. Conceived in the aftermath of 9/11 and previewed at the ACBSA in January 2002,10 the plan includes a sophisticated scalable computer model for evaluating blood shortages and a stockpile of 200 frozen group O RBCs. Providing their complete routine supply of 75 RBC units a day for 3 days would require three cell washers in continuous operation. This throughput approximates the Armed Services Blood Program technical manual, which states that one technician using four cell washers can thaw up to 36 units per 12 hours.11 The major advantage of frozen RBCs would be as partial augmentation to help tide the hospital or blood center over an extended shortage. The authors address questions of training, infectious disease testing, and cost and make the case for this type of program in disaster planning. Fortunately, US blood banking is better prepared for disasters and shortages since 9/11. At the federal level, the importance of the blood supply in disaster planning has been recognized in several ways. The Department of Homeland Security published the 2008 National Response Framework (formerly the 2004 National Response Plan), a general guide for preparing and providing coordinated responses to national emergencies.12 There are 15 emergency support function (ESF) annexes detailing specific areas, and ESF 8 covers public health and medical services under HHS. In this section, HHS’ responsibilities include assessment of the safety and availability of the blood supply as part of the initial event response. Also in ESF 8, HHS monitors the daily national blood supply through the Blood Availability and Safety Information System (BASIS), a voluntary reporting network of more than 100 hospitals and blood centers4 and maintains liaison with the AABB Interorganizational Task Force on Domestic Disasters and Acts of Terrorism. The AABB disaster task force has representatives from major blood supplier and health care organizations and liaisons from HHS, FDA, DoD, the Centers for Disease Control and Prevention, and the Health Resources Services Administration. The task force convenes by telephone and e-mail for event planning, monitoring, and response coordination and has assisted in every major disaster response since 2002, most notably the 2004 and 2005 hurricanes. The group also participates in the TOPOFF series of nationally sanctioned large-scale disaster drills, solving virtual problems posed for local blood supplies in these scenarios. The task force's disaster handbook, expanded in 2008, describes its operations and provides planning information to blood centers and hospitals for more than 15 kinds of events.13 For US hospitals, the Code of Federal Regulations (CFR) for Medicare has several requirements pertaining to emergency preparedness in the hospital environment (42 CFR 482.41(a)), facilities, supplies and equipment (42 CFR 482.41(c)), and emergency services (42 CFR 482.55(b)2, 14). The Medicare assessors’ survey protocol sets out what they are seeking for compliance.15 The Joint Commission (TJC; formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) rapidly expanded its hospital disaster planning requirements from one standard in 2007 to eight standards in 2008 to a new chapter in 2009.16, 17 These TJC standards begin with an annually updated hazard vulnerability analysis and then delineate requirements for a broadly applicable emergency operations plan with six elements: communication, resources, safety and security, staff responsibilities, utilities, and patient needs. The American Osteopathic Association's Healthcare Facilities Accreditation Program, also approved by Medicare, requires a medical disaster committee.18 For transfusion services and blood banks, the 9/11 aftermath brought a new AABB accreditation standard (1.4) for emergency preparedness.19 The AABB Technical Manual now has a chapter on this topic.20 In the 2005 national blood data survey, 99% of blood centers and 90% of hospitals said they had emergency preparedness procedures.1 Hospitals large and small were equally likely to have emergency plans. However, an important question is how well blood banking plans are integrated into those of the hospital and the community. Much has changed since 9/11, but emergency preparedness has become a permanent legacy. The Yale Book of Quotations reminds us that another New Englander, Thomas P. “Tip” O’Neill, popularized the maxim, “All politics is local.”21 Ultimately, all blood banking is also local: a patient, a physician, and the blood product they need. Blood banks and transfusion services each must answer that “what-if” question, marshalling both internal and external resources to meet their responsibility to the patients who will depend on them in a time of crisis.