| 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 |
Specimen Barcode Label Does Not Match Patient Information
A 65-year-old male patient admitted with bleeding anemia due to liver cirrhosis.
Hemoglobin: (6.4) g/dL.
Doctor ordered 2 units of packed red blood cells (PRBC).
The nurse and a new staff member prepare to collect blood for pre-transfusion testing.
After blood draw, the senior nurse notices that the barcode label contains the wrong name and patient ID—different from the patient’s identification band.
Nurse (senior)
Alright, we're ready for collection. Let me check the patient’s wristband. Name: Kihun Jung, ID number: 20230412. No blood type on record yet. New nurse, are the EDTA tubes ready?
Nurse (new)
Yes, I’ve prepared 2 EDTA tubes and printed the barcode labels.
(Passes the label to the senior nurse)
Nurse (senior)
Hold on. Let me see that label… This says Kihwan Jung, ID 20230421. That’s not our patient.
This label belongs to a different person. If we attach this, it could cause a serious transfusion error.
Nurse (senior)
We must discard this sample immediately. This is a patient safety risk. I’ll notify the physician and explain to the patient that we need to recollect the sample.
Nurse (senior)
Mr. Jung, the label we were about to place on your blood sample had another patient’s information.
To prevent any risk, we’ve discarded the sample and will collect a new one. Thank you for your understanding.
Patient
Oh, another blood draw? But I’m really grateful you caught that before anything happened.
Nurse (senior)
Thank you for your patience. This step ensures that you receive the correct and safe transfusion. We’ll begin again shortly.
Nurse (senior)
(Calling Doctor Kim)
Doctor Kim, regarding Kihun Jung (ID: 20230412)—during the blood draw for PRBC transfusion, the barcode label printed by the new nurse showed the wrong name and ID.
We’ve discarded the sample and will recollect. The patient has been informed and consented.
Doctor Kim
Good call. Verifying labels before attaching them is critical. Please proceed with recollection and notify the blood bank.
Nurse (senior)
(Performing recollection)
- Print a new barcode label and double-check with patient ID band
- Prepare two 6 mL EDTA tubes
- Verbally confirm name and ID at bedside
- Collect blood and attach correct label
- Submit request in EMR and send specimen to lab
Nurse (senior)
(EMR Documentation)
🗓 2025.04.08 13:00
- Barcode label printed for pre-transfusion specimen did not match patient (name and ID discrepancy)
- Sample discarded immediately; recollection performed after explanation and consent
- Doctor and blood bank notified
- Vital signs:
BP (110/70) mmHg, HR (92) bpm, Temp (36.7) degrees Celsius, RR (18) breaths/min, SpO₂ (97) percent
Nurse (senior)
(To new nurse)
You must always perform dual verification between the barcode label and the patient’s ID before attaching.
If a mislabeled specimen is processed, the patient could receive incompatible blood, which is life-threatening. Never skip this step, no matter how busy we are.
Nurse (new)
I deeply understand now. I’ll make label verification a strict habit moving forward.
Patient
Thank you all for checking things so thoroughly. That really puts my mind at ease.
Nurse (senior)
We appreciate your patience, Mr. Jung. We’ll ensure your transfusion is done safely and correctly.
✅ Key Learning Points
| Situation | Barcode label on blood specimen did not match patient name and ID |
| Nursing Actions | ① Detected mismatch before label attachment ② Discarded specimen ③ Notified physician ④ Explained to patient ⑤ Recollected and resubmitted correctly |
| Documentation | Included discrepancy, actions taken, communication, patient response, and vital signs |
| Clinical Reminder | Always verify label-patient match before attachment. Mismatched specimens must be discarded and recollected. No exceptions. |
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