The decision to transfuse should be guided by information on the risks and benefits of transfusion. Safer alternatives should be considered. Properly screened blood or components from a reputable source should be used. In this study, a simple, self-educating transfusion request form was developed, and its effects on transfusion practice were assessed, using a cluster-randomized trial. Transfusions at six study hospitals and six control hospitals at four locations in India (Delhi, Bangalore, Nasik and Imphal) were monitored over a 4-month pre-intervention period and a 5-month post-intervention period. During the trial, 56 171 units were transfused to in-patients at the participating hospitals. Among the six intervention hospitals, there was some evidence of a nonsignificant post-intervention reduction in all the three main outcome measures: number of transfusion requests per admission (P = 0.09), number of units transfused per admission (P = 0.11) and number of crossmatches per admission (P = 0.06). No such changes were seen at control sites over the same period. Simple interventions to promote good clinical practice can have an effect, but may be better placed within longer term, broad-based strategies that are able to consider some of the background factors. Lack of clinical training, the hospital environment and fragmented blood bank services influence the way blood is used in India. It is thought that the intervention was ultimately unsuccessful because these factors remained as detrimental influences. A focus on education, policy and infrastructure in line with the new National Blood Policy will be important in coming years.