| 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 Drawn from Wrong Patient with Identical Name
A 68-year-old male patient admitted on day 2 for gastrointestinal bleeding.
Hemoglobin: (6.2) g/dL
Doctor ordered 2 units of packed red blood cells (PRBC) for transfusion.
Two nurses entered the room to collect blood for pre-transfusion testing.
The patient's name is Sungwoo Park, but another patient with the same name is admitted on the same floor.
The new nurse performed the blood draw without checking the ID band and collected the specimen from the wrong Sungwoo Park.
The senior nurse discovered the error during barcode scanning when the patient ID number did not match.
Nurse (senior)
(While scanning the barcode)
Patient name: Sungwoo Park… Wait, the ID number shows 20230413, but our target patient’s number is 20230414.
Nurse (senior)
(To new nurse)
Did you check the patient’s ID band before drawing blood?
Nurse (new)
No, I didn’t. Since the name matched and there was only one person in the room, I assumed it was correct…
Nurse (senior)
That was the wrong Sungwoo Park. This is a critical patient identification error.
We must discard the specimen immediately and collect a new one from the correct patient. I’ll report this to the doctor and explain the situation to both patients.
Nurse (senior)
(Calling Doctor Kim)
Doctor Kim, regarding Sungwoo Park (ID: 20230414) — the new nurse mistakenly drew blood from another patient with the same name.
We’ve discarded the specimen and will recollect from the correct patient. I’ve informed both patients and will proceed with proper documentation.
Doctor Kim
Thanks for the prompt action. This kind of ID check is vital. Make sure the recollection is completed and the incident is documented properly.
Nurse (senior)
(Visiting the patient from whom the wrong sample was drawn)
Mr. Park, earlier today we drew blood thinking it was for your test, but we just confirmed that it was intended for another patient with the same name.
The sample has been discarded, and this won’t affect your care in any way. I sincerely apologize for the confusion.
Patient
Ah, that happens. I didn’t think twice because the name matched. I’m glad you caught the mistake. Thanks for letting me know.
Nurse (senior)
(Visiting the correct patient)
Mr. Park, we’re here to collect blood for your transfusion.
There was a brief mix-up due to another patient having the same name, but we’ve now confirmed everything. We’ll proceed safely.
Patient
I get anxious with these kinds of errors, but I feel much better knowing you double-checked.
Nurse (senior)
Thank you for your understanding. Your calmness helped us handle this properly. We’ll ensure a safe and accurate transfusion.
Nurse (senior)
(Specimen recollection process)
- Double-check patient ID band and electronic medical record
- Prepare two 6 mL EDTA tubes
- Verbally confirm name and ID number at bedside
- Collect blood and attach the correct barcode label
- Submit electronic order and send specimen to the lab
- Provide immediate training to the new nurse on patient ID verification protocol
Nurse (senior)
(EMR documentation)
🗓 2025.04.08 14:10
- Pre-transfusion sample was drawn from another patient with the same name (ID: 20230413)
- Error identified during barcode scan; sample discarded
- Doctor notified; new sample collected from correct patient (ID: 20230414)
- Explanation and reassurance provided to both patients
- Immediate re-education given to new nurse regarding patient verification protocol
- Vital signs:
BP (114/72) mmHg, HR (88) bpm, Temp (36.6) degrees Celsius, RR (18) breaths/min, SpO₂ (97) percent
Nurse (senior)
(To new nurse)
Never rely on patient name alone. Always verify with both name and registration number using the ID band and electronic record.
Errors like this can lead to misdiagnosis or incorrect transfusion. Make this verification process your routine.
Nurse (new)
I understand. I deeply regret the mistake and will never skip ID verification again.
Patient
It’s okay. You’re working hard and doing your best. I appreciate how carefully you’re handling it.
Nurse (senior)
Thank you for your kindness, Mr. Park. We’ll take great care to keep you safe moving forward.
✅ Key Learning Points
| Situation | Blood was drawn from the wrong patient due to identical names |
| Nursing Actions | ① Detected error during barcode scan ② Discarded specimen ③ Reported to doctor ④ Explained to both patients ⑤ Recollected from correct patient ⑥ Re-educated staff |
| Documentation | Includes error description, patient response, corrective actions, and vital signs |
| Clinical Reminder | Identical names require extra care — confirm both name and ID number every time using multiple sources |
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