| 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 |
Unexpected antibody detected during antibody screening test
A 59-year-old female patient admitted for elective total hip replacement surgery.
Preoperative hemoglobin: (9.2) g/dL
Doctor ordered 2 units of PRBC to be prepared in case intraoperative blood loss occurs.
Pre-transfusion tests (ABO/Rh typing, antibody screening, crossmatch) were requested 2 days prior.
Antibody screening results returned positive for unexpected antibody — anti-Kell.
Blood bank unable to release compatible units immediately.
Nurse must coordinate transfusion delay, update the medical team, monitor patient status, and provide emotional support.
Nurse (senior)
Reviewing pre-transfusion test results in EMR. Antibody screening is flagged positive.
Crossmatch status: pending.
Confirmed antibody: anti-Kell detected.
Call to the blood bank initiated for clarification.
Nurse (senior)
This is the ward calling regarding patient Miyeon Park, ID 20230409. Antibody screening result returned positive, and it says anti-Kell was detected. Could you confirm whether compatible PRBC units are available?
Blood bank (via phone)
Yes, we confirmed anti-Kell positivity. We currently don’t have Kell-negative PRBC units on-site. We’ve requested compatible units from the regional blood center, but it may take 4–6 hours.
Nurse (senior)
Turns to the new nurse
Because of this unexpected antibody, the patient can’t receive standard PRBC units. Anti-Kell can cause delayed hemolytic transfusion reactions, so she needs Kell-negative blood only. Let’s notify the doctor and keep the patient NPO in case of surgery postponement.
Nurse (senior)
Ms. Park, I’d like to update you. Your pre-transfusion tests showed the presence of a rare antibody called anti-Kell. This means we need specially matched blood for your safety, which is currently being sourced. The transfusion may be delayed a few hours.
Patient
I see… Does that mean my surgery will be delayed too? I was really nervous about today.
Nurse (senior)
It depends on how quickly we can get compatible blood. Your safety is our top priority, so we’re working with the blood center to get exactly what you need. I know it’s frustrating, but this step is crucial to prevent complications.
Nurse (senior)
(Calling Doctor Lee)
Doctor Lee, this is the nurse in charge of Ms. Park. Her pre-transfusion screening came back positive for anti-Kell antibody. The blood bank confirmed, and no compatible units are currently available on-site. They’re sourcing Kell-negative PRBCs, ETA 4–6 hours.
Doctor Lee
Thanks for the update. Please hold surgery until units arrive. Monitor her hemoglobin, and let me know if there's any sign of bleeding or instability. If anything changes, I’ll reassess.
Nurse (senior)
(Vital signs monitoring and charting in EMR)
🗓 2025.04.08 09:10
- Antibody screening positive for anti-Kell
- Transfusion delayed due to lack of Kell-negative units
- Patient informed and consent obtained for transfusion delay
- Doctor notified
- Vital signs:
BP (124/76) mmHg, HR (82) bpm, Temp (36.8) degrees Celsius, RR (16) breaths/min, SpO₂ (97) percent - Will monitor Hb, signs of bleeding, and patient condition closely
Nurse (senior)
(Later, explaining to the new nurse)
Unexpected antibodies like this can complicate transfusion. It’s why we never skip antibody screening.
If we had administered Kell-positive blood, the patient could have developed alloimmunization or even hemolysis. Always hold transfusion until full compatibility is confirmed.
Nurse (new)
That’s serious… I’ll definitely double-check antibody screening results every time.
Patient
Thank you for explaining everything so clearly. It helps me feel less anxious.
Nurse (senior)
We’ll continue to keep you informed, and as soon as the correct blood arrives, we’ll be ready. You’re doing great — we’re here with you all the way.
✅ Key Learning Points
| Incident | Unexpected antibody (anti-Kell) detected → transfusion delay |
| Nursing Actions | ① Confirm antibody and delay transfusion ② Notify doctor ③ Inform and reassure patient ④ Monitor vitals and status |
| Documentation | EMR entry includes antibody type, delay explanation, patient education, vital signs |
| Clinical Reminder | Unexpected antibodies require specially matched units — standard PRBCs may cause serious reactions |
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