5% Dextrose Infused Concurrently with PRBC → Blood Clotting Occurs → Emergency Intervention

[2] Transfusion Procedure Phase – 10 Possible Error Cases 

1	Omission of pre-transfusion vital signs check
2	Patient and blood verification performed by only one healthcare provider
3	Use of blood transfusion set filter for more than 6 hours
4	Blood transfusion started more than 30 minutes after blood issue
5	Simultaneous administration of 5% dextrose during transfusion → coagulation occurred
6	Transfusion initiated without explaining its purpose and procedure to the patient
7	Storage temperature deviation during transport from blood bank to ward
8	Connection of a different blood product than the physician's order
9	Red blood cells transfused using an infusion pump → red cell damage occurred
10	Use of expired blood bag or one with improper storage conditions

 

 

 

 

 

Scenario 5.  5% Dextrose Infused Concurrently with PRBC → Blood Clotting Occurs → Emergency Intervention

Patient Information
72-year-old female, post-colon cancer surgery with anemia (Hb: 6.2 g/dL)
Ordered: PRBC 2 units. Currently receiving the 1st unit

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Nurse (new)
Ms. Kim, we’re going to begin your PRBC transfusion now.
Since you’re already on a 5% dextrose IV, I’ll connect the blood to the same line.

(5% D/W and PRBC connected concurrently through the same IV line)

(10 minutes into transfusion)

 

Patient
Nurse… I feel a sting and pressure at the IV site… Something doesn’t feel right.

 

Nurse (new)
(checks transfusion line)
Oh no… the blood isn’t flowing, and I see white clumping in the tubing.
Senior nurse! The transfusion has stopped, and something's coagulated in the line!

 

Nurse (senior)
(Immediately stops transfusion)
Stop the transfusion right away and clamp the line.
This looks like blood clotting due to 5% dextrose being infused concurrently.
Dextrose reacts with the additive solution in PRBC and can cause erythrocyte aggregation and clotting.

 

 

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Nurse (senior)
(Calls Doctor Park)
Doctor Park, Ms. Okja Kim (Patient ID: 20250419) developed coagulation in the transfusion line approximately 10 minutes after PRBC was started concurrently with 5% D/W.
Transfusion has been stopped, and the blood bag and set are being preserved for review.

 

Doctor Park
That unit must be immediately discarded—never reused. Maintain the IV line with normal saline only.
What are her vitals?

 

Nurse (senior)
BP (124/78) mmHg, HR (98) bpm, Temp (36.9)°C, RR (20) breaths/min.
She’s stable with no systemic symptoms.

 

Doctor Park
Good. Submit a report to the blood bank for PRBC clotting. Request a new unit for transfusion.

 

 

 

 

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Nurse (senior)
(to new nurse)
Only normal saline (0.9% NSS) can be used concurrently with blood transfusions.
Dextrose can cause hemolysis or clotting by reacting with preservative solutions in blood products.

 

Nurse (new)
I’m really sorry… I assumed any IV fluid was okay. I’ll make sure to verify fluid compatibility going forward.

 

Patient
Did I receive the wrong treatment? Am I going to be okay?

 

Nurse (senior)
You didn’t do anything wrong, Ms. Kim. We identified the issue quickly and took appropriate action.
We’re now keeping your IV line with normal saline and preparing a new unit for transfusion.

 

 

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Nurse (senior)
(EMR Documentation)
🗓 April 13, 2025 – 10:40 AM
• PRBC transfusion stopped 10 minutes in due to visible clotting in the line
• Cause: concurrent infusion with 5% D/W → erythrocyte aggregation
• Transfusion immediately stopped, normal saline line maintained
• Doctor notified; blood bag and set to be discarded and reported to the blood bank
• Request for new PRBC unit initiated
• Vitals: BP (124/78), HR (98), Temp (36.9), RR (20), SpO₂ (96%)
• Patient stable; new transfusion scheduled

 

 

 

 

 

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✅ Key Learning Summary

ItemDetails

Situation	PRBC transfused concurrently with 5% dextrose → clotting observed in line within 10 minutes
Nursing Actions	① Stop transfusion and maintain IV line with normal saline ② Notify physician and report to blood bank ③ Discard PRBC and transfusion set ④ Request new unit ⑤ Educate new nurse and reassure patient
EMR Documentation	Record: transfusion stop time, cause (fluid incompatibility), vitals, physician contact, discard status, new unit requested
Clinical Education Point	✅ Only normal saline can be used during transfusion ✅ Dextrose, LR, and hypotonic solutions can cause hemolysis or clotting ✅ Always verify IV fluids before starting transfusion

 

👉 Catheter Management : CVC, PICC, and Implanted Port (Chemoport)

Catheter Management Scenarios: Central Venous Catheter (CVC), Peripherally Inserted Central Catheter (PICC), and Implanted Port

 

👉 Oxygen Therapy(Nasal prong, Mask, Nebulizer)

Applying a Nasal Prong for Oxygen Therapy

 

👉  Transfusion-10 possible Error 

Scenario 1. Crossmatch Completed, but Blood Bank Sent Mismatched Blood → Nurse Identifies Error During Dual Verification and H

 

5% Dextrose Infused Concurrently with PRBC → Blood Clotting Occurs → Emergency Intervention