| 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 |
Transfusion Order Placed Without Pre-Transfusion Testing
A 72-year-old male patient admitted with pneumonia and congestive heart failure.
Past surgical history noted, but prior hospital records are unavailable.
Today’s morning labs show Hb at (6.7) g/dL.
Doctor placed an order for 2 units of packed red blood cells (PRBC).
Upon nurse review, EMR shows no ABO/Rh typing, antibody screening, or crossmatch performed.
The nurse halts the transfusion process and initiates urgent testing.
Nurse (senior)
(Reviewing EMR before blood bank request)
There’s no blood type recorded, and neither the antibody screen nor crossmatch has been completed.
Although a transfusion order was placed, we cannot proceed without these essential pre-transfusion tests.
Nurse (senior)
(To new nurse)
If we were to start this transfusion without testing, the patient could experience a severe acute hemolytic transfusion reaction.
We must immediately order ABO/Rh typing, antibody screening, and crossmatch.
I’ll inform the doctor and request the tests urgently.
Nurse (senior)
(Calling Doctor Kim)
Doctor Kim, this is the nurse in charge of Sangchul Lee (ID: 20230410).
A transfusion order for PRBC 2 units has been entered this morning, but I found no record of ABO/Rh typing, antibody screening, or crossmatching in the EMR.
Shall we proceed by sending the blood samples for testing first?
Doctor Kim
Thanks for catching that. Yes, please prioritize those tests and notify the blood bank. Let’s get the crossmatch done urgently.
Nurse (senior)
(Prepares for blood sampling with new nurse)
- Verify patient identity using ID band and match it with sample labels
- Use two 6mL EDTA tubes and specific crossmatch labels
- Perform bedside phlebotomy while confirming name and ID
- Label samples immediately and submit test request in the system
Nurse (senior)
Mr. Lee, your morning labs show that your hemoglobin level is quite low, and the doctor has ordered a blood transfusion.
However, your blood type and compatibility tests haven’t been done yet. We’ll draw blood now, send it for testing, and transfuse only when it’s safe to do so.
Patient
So I can’t get the transfusion yet? I’ve been dizzy and short of breath all morning…
Nurse (senior)
I understand how you feel. We’ve already flagged your case as urgent, and we’ll monitor you closely.
If you feel any chest pain, difficulty breathing, or new symptoms, please let me know immediately. I’ll stay close.
Nurse (senior)
(EMR documentation)
🗓 2025.04.08 10:30
- Transfusion order received for PRBC 2 units
- EMR review showed no ABO/Rh typing, antibody screening, or crossmatching performed
- Informed physician and initiated urgent pre-transfusion testing
- Instructed blood bank for priority processing
- Explained situation to patient and obtained understanding
- Vital signs:
BP (102/64) mmHg, HR (96) bpm, Temp (37.1) degrees Celsius, RR (22) breaths/min, SpO₂ (95) percent
Nurse (senior)
(To new nurse)
Even if the order is placed, always verify whether pre-transfusion tests have been completed.
If you skip that and start transfusion, the consequences could be life-threatening.
With transfusions, what we check before we start is more important than how fast we begin.
Nurse (new)
Understood. From now on, I’ll never proceed without confirming all test results first.
Patient
Thank you for being so thorough. I feel reassured knowing you’re keeping a close eye on everything.
Nurse (senior)
You’re welcome, Mr. Lee. Safety comes first. We’re monitoring everything, and you’re in good hands. Let us know right away if anything feels off.
✅ Key Learning Points
| Situation | Transfusion order placed without ABO/Rh typing, antibody screening, or crossmatch |
| Nursing Actions | ① Identified missing tests in EMR ② Informed physician and collected samples ③ Explained delay to patient ④ Monitored vital signs and condition |
| Documentation | Detailed EMR note on testing status, communication with doctor, patient education, and current vitals |
| Clinical Reminder | Never initiate transfusion based solely on a doctor’s order — always confirm pre-transfusion testing is complete |
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