Red Blood Cell Damage Suspected During PRBC Transfusion via Infusion Pump → Immediate Interruption and Emergency Response

[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

Transfusion Procedure Phase – 10 Possible Error Cases 

 

 

 

 

 

 

 

 

Scenario 9. Red Blood Cell Damage Suspected During PRBC Transfusion via Infusion Pump → Immediate Interruption and Emergency Response

 

Situation Overview
Patient: 63-year-old male admitted for upper GI bleeding
Hemoglobin: (6.3) g/dL
Doctor prescribed 2 units of Packed RBCs (PRBC)
Nurse initiated transfusion using an infusion pump, but patient soon complained of arm discomfort and chest tightness; blood in the unit appeared abnormal.

---

Nurse (Senior)
We’ve received 2 units of PRBC for Mr. Seongdo Kim. Let’s begin transfusion preparation.

 

Nurse (New)
IV line is secured with a 20G catheter. Pre-transfusion vitals are:
BP (116/72) mmHg, HR (88) bpm, Temp (36.7) °C, RR (20) breaths/min, SpO₂ (97) percent.
Should I go ahead and start the pump?

 

Nurse (Senior)
Wait—PRBC transfusion via infusion pump must be used only with devices certified for red blood cells. Did you check if this pump model is compatible?

 

Nurse (New)
(Visibly startled) I didn’t verify that… The transfusion has already started. The patient says his arm feels weird.

 

Patient (Mr. Kim)
My arm feels kind of numb… and I’m feeling a bit tight in my chest. Is that normal?

 

Nurse (Senior)
(Immediately halting transfusion) Mr. Kim, I’m stopping the transfusion right now to check things. (Examining the blood unit) The bag looks foamy and discolored… Red blood cell hemolysis is suspected.

---

 

Emergency Nursing Response (Following protocol)
1. Immediately stop the transfusion
2. Recheck vital signs – BP (98/66) mmHg, HR (102) bpm, Temp (37.4) °C, RR (22) bpm, SpO₂ (95)%
3. Maintain IV access using normal saline
4. Retrieve and preserve blood bag and transfusion set → send to blood bank
5. Notify the doctor immediately
6. Closely monitor the patient and provide reassurance
7. Document all actions in the EMR

 

 

 

 

Nurse (Senior)
(Calling the doctor)
Doctor Choi, during PRBC transfusion for Mr. Seongdo Kim, we used an infusion pump. The patient soon reported arm numbness and chest tightness. On inspection, the blood unit appears hemolyzed—foamy and darkened. We’ve stopped transfusion and retained the unit for evaluation.

 

Doctor Choi
You did the right thing. Some pumps can damage red cells if not designed for PRBCs. Monitor him closely. Please order CBC, LDH, and bilirubin to check for hemolysis.

---

Nurse (Senior)
Mr. Kim, we stopped the transfusion because the device might have damaged the blood. You mentioned arm discomfort and chest tightness, and we’re taking every precaution to keep you safe. We’ll get new, safe blood prepared right away.

Patient (Mr. Kim)
That could’ve been serious… I didn’t realize a machine could cause this during a transfusion.

Nurse (Senior)
It’s rare, but that’s why we monitor closely. Thanks to your quick report, we caught it early.

---

Nurse (Senior)
(EMR documentation)

🗓 2025.04.13, 10:20
• PRBC transfusion via infusion pump led to suspected hemolysis.
• Patient complained of arm discomfort and chest tightness 12 minutes after transfusion started.
• Foamy, darkened blood in the unit observed.
• Transfusion immediately halted, line maintained with NSS.
• Blood unit and transfusion set retained and sent to blood bank.
• Doctor notified. Additional labs (CBC, LDH, bilirubin) pending.
• Patient stable.
Vital Signs: BP (98/66) mmHg, HR (102) bpm, Temp (37.4) °C, RR (22) bpm, SpO₂ (95)%

 

 

 

---

Nurse (Senior)
(To the new nurse)
Always check whether a pump is approved for PRBC before using it. Gravity drip is safest for red cells. If the patient reports symptoms or if you see changes in the blood bag, stop immediately and assess for hemolysis.

 

Nurse (New)
I understand now. I’ll always verify the equipment before transfusing PRBCs.

 

Patient (Mr. Kim)
I really appreciate how carefully you handled everything. I feel a lot safer now.

 

Nurse (Senior)
Thanks for staying calm. We’ll prepare the correct blood and continue safely. We’re here for you.

 

 

👉 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

 

Red Blood Cell Damage Suspected During PRBC Transfusion via Infusion Pump → Immediate Interruption and Emergency Response