| No. | Error Case (Pre-Transfusion Testing Phase) |
|---|---|
| 1 | Mismatch between the patient's actual blood type and medical records |
| 2 | Unexpected antibody detected during antibody screening test |
| 3 | Transfusion ordered without performing pre-transfusion testing |
| 4 | ABO and Rh test results missing → Blood release denied by the blood bank |
| 5 | Barcode label on specimen does not match patient information |
| 6 | Specimen collected from a different patient with the same name |
| 7 | Using test results older than 72 hours for patients with repeated transfusions |
| 8 | Positive result in crossmatching → Blood product needs to be changed |
| 9 | Emergency transfusion attempted before completing crossmatch test |
| 10 | Pre-transfusion testing performed without checking past adverse transfusion history |
Mismatch between the patient's actual blood type and medical records
A 67-year-old male patient with a diagnosis of upper gastrointestinal bleeding.
Hemoglobin: (6.9) g/dL.
Doctor prescribed 2 units of packed red blood cells (PRBC).
ABO/Rh typing, antibody screening, and crossmatching were completed.
Patient’s confirmed blood type is B Rh(positive).
1 unit of PRBC arrived from the blood bank labeled as A Rh(positive).
The error was identified during the dual verification process performed by two nurses.
Nurse (senior)
Alright, let’s begin the final verification process before initiating the transfusion. Please check the patient’s ID band.
Nurse (new)
The ID band reads: Yongsoo Kim, ID number 20230408, blood type B Rh(positive).
Nurse (senior)
Hold on… The blood unit label says A Rh(positive). Blood unit number 889201. The crossmatch is marked complete, but the blood type doesn’t match the patient’s.
Nurse (new)
That’s strange. How could a mismatched blood type be sent even after crossmatching?
Nurse (senior)
Even when crossmatching is completed, final bedside verification is critical. This could lead to a hemolytic transfusion reaction if administered.
Let’s stop the transfusion process immediately. Place the unit back into the thermal transport container. I’ll notify the blood bank and explain the situation to the patient.
Nurse (senior)
Mr. Kim, we’re pausing the transfusion for your safety. During our final verification, we found that the blood unit delivered does not match your blood type. We're in the process of clarifying with the blood bank.
Patient
But I’m B type… They sent something else? Is this dangerous?
Nurse (senior)
You did nothing wrong, and the transfusion hasn’t started yet, so you're safe. It’s exactly why we have this verification step. We’ll make sure the correct unit is delivered shortly.
Nurse (senior)
(Blood bank call)
This is the ward calling regarding patient Yongsoo Kim (ID: 20230408). We were about to start a PRBC transfusion, but the unit received is labeled A Rh(positive).
The patient's confirmed blood type through ABO/Rh typing and EMR is B Rh(positive), and crossmatch was completed. Please check if an incorrect unit was issued and re-send the correct one.
Nurse (senior)
(Calling the doctor)
Doctor Kim, this is the nurse in charge of Mr. Kim. During the final check before transfusion, we discovered that the PRBC unit sent is labeled A Rh(positive), which doesn’t match the patient’s B Rh(positive) type.
The transfusion has been held, and the blood bank has been notified to reissue the correct unit. The patient remains stable at the moment.
Doctor Kim
Good call. Even after crossmatch, bedside verification is crucial. Please resume transfusion once the correct unit arrives, and reassess the patient’s vital signs before starting.
Nurse (senior)
(Charting in EMR)
🗓 2025.04.08, 14:40
- Transfusion halted prior to initiation due to discrepancy found during dual verification. Blood unit label: A Rh(positive); patient type: B Rh(positive).
- Transfusion not initiated. Blood bank and attending physician notified immediately.
- Reissue requested. Patient currently stable.
- Vital signs:
BP: (118/70) mmHg
HR: (85) beats/min
Temp: (36.6) degrees Celsius
RR: (18) breaths/min
SpO₂: (96) percent
Nurse (senior)
This was a critical catch. Just because crossmatching is done doesn’t mean we skip final checks.
Always verify patient name, ID number, blood type, blood component, expiration date, and compatibility label. We prevented a serious adverse event today by staying alert.
Nurse (new)
I’ve learned a big lesson today. Crossmatch doesn’t mean it's 100% safe. Final verification is essential.
Patient
I’m sorry for the trouble. I feel bad delaying the treatment.
Nurse (senior)
Not at all. Thanks to your patience, we handled this safely. We’ll make sure the correct blood is ready and resume your transfusion shortly. You’re doing great.
✅ Key Learning Points
| Incident | Crossmatched blood sent from the blood bank had the wrong blood type |
| Nursing Actions | ① Dual verification revealed error ② Transfusion halted ③ Blood bank and physician notified ④ Patient informed and reassured |
| Documentation | EMR entry includes time of discovery, mismatch details, actions taken, and vital signs |
| Clinical Reminder | Crossmatch ≠ Skip verification — nurses are the final safeguard before transfusion |
