| 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 |
Repeated Transfusion Patient with Pre-Transfusion Test Older Than 72 Hours
A 70-year-old male patient undergoing chemotherapy for gastric cancer.
He receives regular transfusions due to chemotherapy-induced anemia.
Today’s hemoglobin: (6.8) g/dL
Doctor ordered 1 unit of PRBC.
EMR shows pre-transfusion testing (ABO/Rh typing, antibody screen) was done 4 days ago (96 hours prior).
Nurse requests blood based on previous results, but the blood bank refuses to issue the unit due to outdated testing.
Urgent recollection is required.
Nurse (senior)
(Reviewing EMR)
Mr. Seo’s last transfusion test was done on April 4th, and today’s the 8th. That’s already 4 days ago… over 72 hours.
But the transfusion was ordered just now. Let me confirm with the blood bank.
Nurse (senior)
(Calls blood bank)
Hi, I’m calling from the ward about Seojin Seo, ID 20230415. We requested 1 unit of PRBC based on the April 4th testing. Is the blood ready?
Blood bank
That test is now older than 72 hours. We can’t release blood without a new pre-transfusion specimen. Please recollect and resend the request.
Nurse (senior)
(To new nurse)
Even for repeat transfusion patients, ABO/Rh typing and antibody screening are only valid for 72 hours, due to the possibility of new alloantibody development.
We’ll need to recollect and explain the reason to the patient.
Nurse (senior)
Mr. Seo, your hemoglobin is low again, and we planned for another transfusion.
However, the last blood compatibility test was done more than 3 days ago. For your safety, we need to repeat the test today before proceeding.
Patient
Oh… I thought it was already done. I get these transfusions all the time, why do I need another test?
Nurse (senior)
Since your immune system can change with every transfusion, new antibodies might form.
Testing again every 72 hours ensures that you receive perfectly matched and safe blood. The blood bank enforces this strictly.
Patient
Alright… if it keeps me safe, I’ll do it.
Nurse (senior)
(Calling Doctor Lee)
Doctor Lee, regarding Mr. Seo, the blood bank declined PRBC release due to his last pre-transfusion test being 96 hours old.
I’ve explained this to the patient and will now recollect and submit a new sample.
Doctor Lee
Understood. Thanks for checking the timing. Let me know once the blood is ready again.
Nurse (senior)
(Blood collection procedure)
- Verify name and registration number using ID band
- Prepare 1 EDTA tube for ABO/Rh and antibody screen
- Confirm patient verbally: name and birthdate
- Draw blood and apply new barcode label
- Submit order in EMR and send to lab urgently
- Notify blood bank for urgent crossmatch once results are ready
Nurse (senior)
(EMR documentation)
🗓 2025.04.08 11:50
- PRBC 1 unit transfusion ordered; pre-transfusion test dated April 4 found to be over 72 hours old
- Blood bank refused release; patient informed and consented to recollection
- New specimen collected and submitted urgently
- Vital signs:
BP (118/74) mmHg, HR (87) bpm, Temp (36.9) degrees Celsius, RR (18) breaths/min, SpO₂ (97) percent
Nurse (senior)
(To new nurse)
Many people assume frequent transfusion patients don’t need repeat testing. But antibodies can form anytime, especially after repeated exposure.
That’s why 72 hours is the max window. Always check the test date before requesting blood.
Nurse (new)
Thank you. I won’t just assume the old test is fine anymore. I’ll check every time.
Patient
Thanks for explaining everything clearly. I trust you’re doing the best for me.
Nurse (senior)
Of course, Mr. Seo. We’ll proceed as soon as the test result comes back.
✅ Key Learning Points
| Situation | Attempted to use pre-transfusion test result older than 72 hours → blood bank refused release |
| Nursing Actions | ① Confirmed outdated test ② Explained to patient ③ Recollected specimen ④ Reported to doctor ⑤ Re-requested blood |
| Documentation | Included reason for rejection, patient response, recollection action, and vital signs |
| Clinical Reminder | Pre-transfusion testing is only valid for 72 hours — always verify test date before requesting blood |
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