Blood Transfusion Set Filter Used Beyond 6 Hours → Febrile Reaction → Emergency Response and Preventive Measures

 

[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 3. Blood Transfusion Set Filter Used Beyond 6 Hours → Febrile Reaction → Emergency Response and Preventive Measures

Patient Information
68-year-old male, diagnosed with gastrointestinal bleeding and anemia
Hemoglobin: (6.4) g/dL, prescribed 3 units of PRBC
After 2 units transfused with the same filter, the 3rd unit was started using the same transfusion set beyond 6 hours
The patient developed symptoms 20 minutes after starting the 3rd unit

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Nurse (new)
Mr. Kim, I’ll begin your final unit of PRBC now. I’ll continue using the same transfusion set we used earlier.

(The nurse connects the 3rd PRBC unit using the same set without checking elapsed time)

(20 minutes into transfusion)

 

Patient
Nurse… I feel really cold… and my head hurts too… I’m shivering.

 

Nurse (new)
You’re feeling chills and a headache? Let me check your temperature.
Temp (38.6) degrees Celsius, BP (130/78) mmHg, HR (104) bpm, RR (20) breaths/min.

 

Nurse (new)
(Very concerned) You have a fever. Something’s not right. Senior nurse, could you come help?

 

Nurse (senior)
(Checks the transfusion set) When did this set start being used?

 

Nurse (new)
Uh… the first unit was started around 9 a.m. and this is the 3rd unit…

 

Nurse (senior)
It’s well past 6 hours. The transfusion filter must be replaced after 6 hours or after 2–4 units. Using an old filter increases the risk of contamination. This may be a febrile non-hemolytic transfusion reaction (FNHTR). Stop the transfusion immediately.

 

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Nurse (senior)
(Calling Doctor Park)
Doctor Park, this is regarding Mr. Youngsoo Kim (ID: 20250414). He developed chills, fever (38.6°C), and headache 20 minutes after starting the 3rd unit of PRBC using a filter that had been in use for over 6 hours.
Vitals are BP (130/78), HR (104), Temp (38.6), RR (20). Transfusion has been stopped, and we’re preparing a new set.

 

Doctor Park
Good call. Stop the transfusion, administer Acetaminophen 650mg IV, and monitor symptoms. If worsens, consider Chlorpheniramine. After stabilization, resume transfusion with a fresh set. Keep the blood bag and transfusion set for the blood bank.

 

 

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Nurse (senior)
(To new nurse) The transfusion set must be replaced every 2–4 units or within 6 hours. If more than 1 hour has passed between units, always use a new filter. Time-checking is non-negotiable.

 

Nurse (new)
I’m so sorry… I didn’t realize the time had passed...

 

Nurse (senior)
It’s okay. Mistakes happen. Luckily the patient reported symptoms early. Let’s document this and learn from it.

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Nurse (senior)
(To patient)
Mr. Kim, we’ve paused the transfusion because you developed chills and fever. It’s likely due to the transfusion equipment being used for too long. You’re receiving medication now and should feel better shortly.

 

Patient
Did I do something wrong? Will I be okay?

 

Nurse (senior)
No, you did nothing wrong. It’s a system issue, and we caught it early. We’re taking every precaution to ensure your safety. I’ll stay with you to monitor.

 

 

 

 

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Nurse (senior)
(EMR Documentation)
🗓 April 13, 2025 – 3:30 PM
• Febrile symptoms (38.6°C), chills, and headache occurred 20 minutes into the 3rd PRBC unit → transfusion stopped
• Filter had been in use for over 6 hours
• Transfusion set and blood bag preserved and will be sent to blood bank
• Doctor notified, Acetaminophen 650mg IV administered
• Vitals: BP (130/78), HR (104), Temp (38.6), RR (20)
• Patient stable, transfusion to resume later with a new set

 

 

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✅ Key Learning Summary

ItemDetails

Situation	3rd unit of PRBC transfused using a filter beyond the 6-hour usage limit → febrile non-hemolytic reaction developed
Nursing Actions	① Stop transfusion and reassess vitals ② Report to physician and administer Acetaminophen 650mg IV ③ Preserve blood bag and set → send to blood bank ④ Prepare new set for later transfusion ⑤ Educate new nurse on transfusion filter policy
EMR Documentation	Document transfusion stop time, symptoms, vitals, identified cause (expired filter), physician instructions, medication given, and reporting
Clinical Education Point	✅ Filters must be changed every 2–4 units or within 6 hours ✅ If ≥1 hour elapses between units, use a new filter ✅ Failing to follow these rules increases infection and reaction risk—time-tracking is critical

 

 

 

 

👉 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 Transfusion Set Filter Used Beyond 6 Hours → Febrile Reaction → Emergency Response and Preventive Measures