| 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 |
Blood Bank Refuses to Issue Blood Due to Missing ABO and Rh Typing Results
A 75-year-old female patient admitted for chronic kidney disease (CKD) management.
Morning hemoglobin result: (7.0) g/dL
Doctor ordered 1 unit of packed red blood cells (PRBC) for transfusion.
Although the patient's historical blood type is documented (B Rh positive),
no ABO and Rh typing test was performed within the last 72 hours.
Crossmatch was requested, but the blood bank refused to issue the blood.
The nurse contacted the blood bank, confirmed the missing results, reported to the physician, and initiated urgent sample collection.
Nurse (senior)
(Reviewing transfusion order and attempting crossmatch request)
PRBC 1 unit ordered. Patient history shows B Rh(positive), but I need to verify.
Crossmatch request submitted. I’ll call the blood bank to confirm blood availability.
Nurse (senior)
(Calling blood bank)
This is the ward. I’m calling about patient Junghee Kim, ID number 20230411. We submitted a crossmatch request. Is the blood ready?
Blood bank
There are no ABO and Rh typing results available within the last 72 hours.
We cannot proceed with the crossmatch or release any blood. Please perform updated blood typing and resend the request.
Nurse (senior)
(To new nurse)
Even if the patient’s blood type is on record, we need an updated ABO/Rh test within 72 hours for any transfusion.
Without it, the blood bank won’t release the blood. Let’s explain the situation to the patient and draw new samples.
Nurse (senior)
Ms. Kim, we requested blood for transfusion, but the blood bank informed us that your recent blood type test is missing.
We’ll need to do a quick blood draw to confirm your type, and once we get the result, we’ll proceed with the transfusion.
Patient
But I already had blood work done during my last admission… Do I really need another test? I’m worried I won’t get the blood today.
Nurse (senior)
I understand, but for your safety, we can’t proceed without a current test.
We’re prioritizing your case so the results come back as soon as possible.
Nurse (senior)
(Calling Doctor Lee)
Doctor Lee, this is regarding Ms. Junghee Kim. She was scheduled for PRBC transfusion today, but the blood bank refused to issue the blood due to missing recent ABO and Rh results.
I’m drawing new samples now and will expedite the testing so we can proceed once results are back.
Doctor Lee
Thanks for the update. Yes, proceed with the testing and let me know as soon as the crossmatch is completed. Please inform the blood bank as well.
Nurse (senior)
(Blood sample collection and request process)
- Verify patient ID band and match it with specimen label
- Collect 1 EDTA tube
- Attach ABO/Rh-specific label
- Enter lab request in EMR system
- Deliver sample to pathology and request urgent processing
Nurse (senior)
(EMR Documentation)
🗓 2025.04.08 11:05
- PRBC 1 unit transfusion scheduled; blood bank refused release due to no ABO/Rh test within 72 hours
- Physician notified; patient informed and consent obtained
- New sample drawn and sent for urgent testing
- Vital signs:
BP (108/68) mmHg, HR (90) bpm, Temp (36.5) degrees Celsius, RR (20) breaths/min, SpO₂ (96) percent
Nurse (senior)
(To new nurse)
It’s a common mistake to rely on past records. For transfusion, the ABO and Rh typing must be current — within 72 hours.
Even if it seems redundant, skipping this step can lead to serious risk. Make it a habit to verify before every transfusion.
Nurse (new)
Thank you. I’ll make sure to always check for updated test results from now on.
Patient
Sorry to cause all this trouble…
Nurse (senior)
Not at all. Your safety matters most, and we appreciate your understanding.
We’ll resume the transfusion as soon as the correct results are back.
✅ Key Learning Points
| Situation | Missing ABO and Rh typing results → crossmatch not possible → blood bank refuses to release blood |
| Nursing Actions | ① Confirmed with blood bank ② Reported to physician ③ Explained to patient and obtained consent ④ Collected and submitted urgent specimen |
| Documentation | Reason for delay, physician notification, patient education, and vital signs documented in EMR |
| Clinical Reminder | Transfusion requires ABO/Rh typing within 72 hours — historical records are insufficient |
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