Blood Temperature Deviation During Ward Transfer → Transfusion Withheld and Blood Discarded

[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 7. Blood Temperature Deviation During Ward Transfer → Transfusion Withheld and Blood Discarded

Patient Information
78-year-old female, diagnosis: gastrointestinal bleeding with moderate anemia
Hemoglobin: (6.7) g/dL, PRBC 1 unit prescribed
PRBC unit issued from the blood bank at 10:00 AM
During transport to the ward, the nurse was interrupted by an emergency call, and the unit was left at room temperature for over 40 minutes

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Nurse (new)
Senior nurse, I’ll go ahead and set up the PRBC for Ms. Kim.
(Opens the transport cooler) Hmm… the container feels warm.

 

Nurse (senior)
What time is it now? The unit was issued at 10:00, and it’s 10:45 now.
I remember you were called away for that emergency response earlier, right?

 

Nurse (new)
Yes... I’m sorry. I got pulled away to respond to a patient code and didn’t realize the time had passed.

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Nurse (senior)
Blood must be used within 30 minutes of issue.
If it has been kept outside the required 1–6°C range, there’s a high risk of bacterial growth.
This unit is no longer safe for transfusion and must be discarded immediately.

 

Nurse (new)
Understood. I’ll discard it and submit a new request for another unit.

 

 

 

 

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Nurse (senior)
(Calling Doctor Lee)
Doctor Lee, this is regarding patient Myungja Kim (ID: 20250420).
A unit of PRBC was issued at 10:00 AM, but due to an emergency, it remained at room temperature for over 40 minutes during ward transfer.
Temperature deviation confirmed. Transfusion has been withheld, and the blood unit will be discarded. A new unit has been requested.

 

Doctor Lee
Good call. Any unit outside the temperature range must never be used. Please document and notify the blood bank accordingly.

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Nurse (senior)
(To patient)
Ms. Kim, the blood we received was exposed to room temperature for too long due to an unexpected situation.
To ensure your safety, we are withholding the transfusion and will request a new, safe unit for you shortly.

 

Patient
Oh my… Am I okay? It sounds like I could have been harmed?

 

Nurse (senior)
You’re completely fine. It’s a good thing we double-checked. We’ll proceed with a fresh unit that meets all safety standards.

 

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Nurse (new)
(EMR Documentation)
🗓 April 13, 2025 – 10:50 AM
• PRBC unit issued at 10:00 AM
• Due to emergency response, unit was exposed to room temperature for 45 minutes → temperature deviation confirmed
• Transfusion withheld, blood discarded, and new unit requested
• Doctor Lee notified, blood bank informed
• Patient stable and awaiting new unit
• Vitals: BP (122/76) mmHg, HR (84) bpm, Temp (36.7)°C, RR (18)

 

 

 

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✅ Key Learning Summary

ItemDetails

Situation	PRBC unit was left at room temperature for over 40 minutes during transfer from blood bank to ward
Nursing Actions	① Check elapsed time and blood condition ② Withhold transfusion ③ Notify physician and discard blood ④ Request new unit ⑤ Inform and reassure patient
EMR Documentation	Include issue and exposure time, reason for discard, physician contact, vital signs, and replacement request
Clinical Education Point	✅ PRBC must be stored at 1–6°C, and used within 30 minutes of issue ✅ Any deviation from temperature protocol requires discard and reissue ✅ Safety checks before transfusion are critical to patient outcomes

👉 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

Blood Temperature Deviation During Ward Transfer → Transfusion Withheld and Blood Discarded