The new Indian National Blood Policy intends to improve the provision of easily accessible safe blood and blood components, available according to need. There is a requirement for information on patterns of blood transfusion in India, to help understand the potential for changes in transfusion practice and the organization of blood services, and to help ensure optimal use of this valuable and limited human resource. This study involved a questionnaire survey of blood transfusion practice with reference to Indian National AIDS Control Organisation clinical guidelines at selected blood centres in four study areas (Delhi, Bangalore, Nasik District and Imphal). Information on 1062 transfusion episodes was analysed. Adult recipients accounted for 87% of transfusions, and amongst the age group of 25-34, 73% of transfusions were to women. Anaemia was listed as a reason for 60% of transfusions, surgery for 42%, acute haemorrhage for 26% and pregnancy for 16%. Seventy-four per cent of adult transfusions were inappropriate when assessed against criteria derived from government transfusion guidelines. Possible common proximate causes for inappropriate transfusions include unnecessary transfusion for iron-deficiency anaemia and transfusion as a first choice for volume replacement. Options to promote good transfusion practice in India should be appraised.