[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 4. Blood Transfusion Started After 30 Minutes of Issue Time → Febrile Reaction Occurs → Emergency Response
Patient Information
74-year-old female, diagnosis: chronic kidney disease, history of prior transfusions
Recent Hb: (6.1) g/dL. PRBC 1 unit ordered
Blood was issued from the blood bank at 9:00 AM, but transfusion was not started until 9:35 AM (over 30 minutes later)
Fifteen minutes after transfusion began, the patient exhibited symptoms
Nurse (new)
Ms. Lee, I’ll begin your PRBC transfusion now. (preparing blood bag that had remained at room temperature)
I’ve rechecked your wristband and blood label. Starting the transfusion.
(Blood issued at: 9:00 / Transfusion started at: 9:35)
(15 minutes into transfusion)
Patient
Nurse… I feel cold and nauseous… I’m shivering. Is this normal?
Nurse (new)
Let me check your temperature.
Temp (38.4) degrees Celsius, BP (126/74) mmHg, HR (106) bpm
Do you have chills and a headache too?
Patient
Yes… my head is pounding. I don’t feel right…
Nurse (new)
(panicking slightly) Senior nurse! Ms. Lee is showing signs of a reaction—fever and chills within 15 minutes of transfusion!
Nurse (senior)
(checks label) When was this blood issued?
Nurse (new)
At 9:00, but there was a delay due to lab work… I started it around 9:35.
Nurse (senior)
Blood must be started within 30 minutes of issue to avoid bacterial growth risk.
This could be a febrile non-hemolytic transfusion reaction (FNHTR) or even an early septic reaction. Stop the transfusion immediately.
Nurse (senior)
(Calling Doctor Kim)
Doctor Kim, Ms. Soonja Lee (Patient ID: 20250415) developed chills, nausea, and a headache with a temperature of (38.4°C), 15 minutes after PRBC transfusion began.
The blood was issued at 9:00 but wasn’t started until 9:35—exceeding the 30-minute safe window. Transfusion has been stopped.
Doctor Kim
Thanks for the quick action. Blood not started within 30 minutes must be discarded. Administer Acetaminophen 500mg IV, monitor closely, and send the blood bag and transfusion set to the blood bank. Also, file a transfusion reaction report.
Nurse (senior)
(to new nurse) Blood must be started within 30 minutes of issue, and transfused within 4 hours.
Once it’s out of refrigeration, microbial growth becomes a risk. Always check and document the issue time.
Nurse (new)
I’m really sorry… I checked the label but didn’t pay attention to the clock…
Nurse (senior)
It’s a common oversight. The important thing is we caught it early. Just remember to always verify and document both issue and start times.
Nurse (senior)
(to patient)
Ms. Lee, we stopped the transfusion because you developed a fever and chills.
The blood had been out too long before starting, which can pose a risk of contamination. You’ve been given medication, and we’ll monitor you closely.
Patient
Was the blood bad? Am I going to be okay?
Nurse (senior)
You’ll be okay. We stopped it in time and took the necessary precautions. I’ll stay nearby to check on you.
Nurse (senior)
(EMR Documentation)
🗓 April 13, 2025 – 9:50 AM
• Febrile symptoms (Temp: 38.4°C), chills, headache, nausea occurred 15 minutes into PRBC transfusion → transfusion stopped
• Blood had been issued at 9:00, started at 9:35 (exceeding 30-minute safe window)
• Doctor notified, Acetaminophen 500mg IV administered
• Blood bag and transfusion set preserved for return to blood bank
• Transfusion reaction report in progress
• Vitals: BP (126/74), HR (106), Temp (38.4), RR (20)
• Patient stable and under observation
✅ Key Learning Summary
| Situation | PRBC transfusion started over 30 minutes after blood was issued, resulting in febrile and systemic symptoms |
| Nursing Actions | ① Stop transfusion immediately ② Recheck vitals ③ Report to physician and administer Acetaminophen 500mg IV ④ Preserve blood bag & set → send to blood bank ⑤ File transfusion reaction report |
| EMR Documentation | Include: transfusion start time, symptom onset, vitals, suspected cause, physician instructions, preservation & reporting |
| Clinical Education Point | ✅ Always start transfusion within 30 minutes of issue and complete within 4 hours ✅ Exceeding time limits increases infection risk—time tracking is critical ✅ Label and monitor time as part of standard workflow |
👉 Catheter Management : CVC, PICC, and Implanted Port (Chemoport)
Catheter Management Scenarios: Central Venous Catheter (CVC), Peripherally Inserted Central Catheter (PICC), and Implanted Port
Contents🔹 1. Understanding Central Venous Catheters (CVC), PICC Lines, and Chemoports 💡 Central venous catheters, peripherally inserted central catheters (PICC), and chemoports are used based on the patient's clinical cond
ganohama.com
👉 Oxygen Therapy(Nasal prong, Mask, Nebulizer)
Applying a Nasal Prong for Oxygen Therapy
👀 Tracheostomy Care – Managing tracheostomy and preventing infections👀 Suctioning – Procedures for secretion removal and safe execution👀 Oxygen Therapy – Proper oxygen usage and application to patients (Nasal Cannula, Simple Oxyge
working.ganohama.com
👉 Transfusion-10 possible Error
Scenario 1. Crossmatch Completed, but Blood Bank Sent Mismatched Blood → Nurse Identifies Error During Dual Verification and H
No.Error Case (Pre-Transfusion Testing Phase)1Mismatch between the patient's actual blood type and medical records2Unexpected antibody detected during antibody screening test3Transfusion ordered without performing pre-transfusion testing4ABO and Rh test re
ganohama.com
