| 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 |
Pre-transfusion Testing Performed Without Verifying Past Transfusion Reaction History
A 74-year-old male patient is hospitalized for chronic kidney disease.
He has received two PRBC transfusions in the past month.
Today, his hemoglobin level is (7.2) g/dL, and 1 unit of PRBC is prescribed.
A new nurse performs the pre-transfusion testing (ABO/Rh and antibody screen) but does not check the patient's past transfusion reaction history.
After blood is drawn, the patient voluntarily mentions that he experienced chills and fever during a previous transfusion.
Nurse (new)
(After completing blood draw)
Mr. Kang, we’ve finished the pre-transfusion blood tests. The transfusion will likely be done later today.
Patient
Last time I had a transfusion… I remember feeling really cold and started shaking. Could that have been from the blood?
Nurse (new)
Did you experience fever or chills during the previous transfusion?
Patient
Yes, it happened less than an hour into the transfusion — I was shivering and had a fever. The nurse had to stop it, I think.
Nurse (new)
(Immediately informs the senior nurse)
Mr. Kang just said he had a reaction during his last transfusion — fever and chills.
I didn’t check his history before drawing the sample. What should we do?
Nurse (senior)
Good catch. It’s not an emergency, so it’s lucky we found out now.
Let’s review his chart and confirm any past adverse reactions. I’ll report this to the doctor and request a leukocyte-reduced PRBC and premedication.
Nurse (senior)
(Calls Doctor Lee)
Doctor Lee, regarding Mr. Kang Wonsik (ID: 20230420), he just disclosed a febrile and chills reaction during a previous transfusion.
Chart review shows the transfusion was stopped in March due to suspected febrile non-hemolytic transfusion reaction (FNHTR).
We’d like to request leukocyte-reduced RBC and administer Acetaminophen and Chlorpheniramine as premedication.
Doctor Lee
Good job catching that. I’ll add the premed orders. Make sure to administer the medications 30 minutes prior to transfusion and send a new request for leukocyte-reduced RBC.
Nurse (senior)
(To patient)
Mr. Kang, thank you for remembering and sharing that reaction.
To prevent that from happening again, we’ll give you premedication and use a specially processed blood product that reduces the chance of side effects.
Patient
That makes me feel a lot better. I was worried it might happen again.
Nurse (senior)
(EMR documentation)
🗓 2025.04.08 15:50
- Patient verbally reported chills and fever during previous transfusion
- Chart review confirmed transfusion stopped on 2025.03.17 due to suspected FNHTR
- Doctor notified; ordered leukocyte-reduced RBC and premedication
- Premeds: Acetaminophen 650 mg PO, Chlorpheniramine 4 mg IV, to be administered 30 minutes prior to transfusion
- Vital signs stable:
BP (122/68) mmHg, HR (84) bpm, Temp (36.6) °C, RR (18) breaths/min, SpO₂ (98) percent
Nurse (senior)
(To new nurse)
Before any transfusion, always check the patient’s previous transfusion reaction history.
Even if there’s nothing in the EMR, it’s crucial to ask the patient directly.
This time, we were lucky the patient told us — now we can proceed safely.
Nurse (new)
I’m really sorry. From now on, I’ll make sure to check both the chart and ask the patient before doing anything.
Patient
Thanks to you both, I feel much safer this time. I appreciate your care.
✅ Key Learning Points
| Situation | Pre-transfusion testing performed without reviewing patient’s history of adverse transfusion reactions |
| Nursing Actions | ① Patient disclosed past FNHTR ② Chart review confirmed history ③ Doctor notified ④ Leukocyte-reduced RBC requested ⑤ Premeds ordered and administered |
| Documentation | Included patient report, chart findings, doctor’s order, medication names, and vital signs |
| Clinical Reminder | Always confirm prior transfusion reactions — through EMR and direct patient inquiry — before ordering or initiating transfusion |
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
