Single-Person Blood and Patient Verification→ Acute Hemolytic Reaction Occurs → Full Emergency Protocol Activated

[2] Transfusion Procedure Phase – 10 Possible Error Cases 

1	Omission of pre-transfusion vital signs check
2	Patient and blood verification performed by only one healthcare provider
3	Use of blood transfusion set filter for more than 6 hours
4	Blood transfusion started more than 30 minutes after blood issue
5	Simultaneous administration of 5% dextrose during transfusion → coagulation occurred
6	Transfusion initiated without explaining its purpose and procedure to the patient
7	Storage temperature deviation during transport from blood bank to ward
8	Connection of a different blood product than the physician's order
9	Red blood cells transfused using an infusion pump → red cell damage occurred
10	Use of expired blood bag or one with improper storage conditions

 

 

 

 

 

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Scenario 2. Single-Person Blood and Patient Verification → Acute Hemolytic Reaction Occurs → Full Emergency Protocol Activated

Patient Information
78-year-old female, admitted for rehabilitation after femur fracture surgery
Hemoglobin: (6.3) g/dL. Ordered PRBC 1 unit for transfusion
New nurse initiated transfusion after verifying patient and blood alone. After 10 minutes, the patient's condition worsened suddenly.

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Nurse (new)
Ms. Cho, I’ll begin the transfusion now. I’ve checked your wristband and the blood unit. Starting the PRBC now.

(Transfusion initiated after single-nurse verification)

(10 minutes later)

 

Patient
My back really hurts, and I feel so cold… I feel nauseous too…

 

Nurse (new)
You’re feeling chills and back pain? Let me check your vitals right away.
BP (82/54) mmHg, HR (118) beats/min, Temp (38.5) degrees Celsius, RR (24) breaths/min, SpO₂ (90) percent.
This looks serious. Stopping the transfusion immediately and replacing the line with normal saline. Senior nurse, I need help here!

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Nurse (senior)
(Steps in and checks the setup) Keep the blood bag and transfusion set intact. Clamp the line but don’t discard anything. This looks like an acute transfusion reaction. I’ll call the doctor now.

 

Nurse (senior)
(Calling Doctor Kim)
Doctor Kim, this is regarding Ms. Youngja Cho (ID: 20250414). She developed chills, lower back pain, fever (38.5°C), and hypotension (BP 82/54) about 10 minutes after starting PRBC transfusion.
Transfusion was stopped immediately. We’re preserving the blood bag and transfusion set for investigation.

 

Doctor Kim
This may be an acute hemolytic transfusion reaction. Please order the following tests:
• CBC
• Coombs test (Direct Antiglobulin Test)
• LDH
• Total & Direct Bilirubin
• Haptoglobin
• Urinalysis (check for hemoglobinuria)
Administer Acetaminophen 500 mg IV and maintain IV fluids. If symptoms worsen, give Hydrocortisone 100 mg IV. Also notify the blood bank and infection control team, and file a transfusion reaction report.

 

 

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Nurse (senior)
(To new nurse)
Please prepare to send the preserved blood bag, used transfusion set, and a fresh EDTA sample to the blood bank.
Also, complete the Transfusion Reaction Incident Report and send it to the unit, blood bank, and infection control team.

 

Nurse (new)
(teary-eyed) I’m so sorry… I started the transfusion alone without a second verifier…

 

Nurse (senior)
That’s okay. What matters now is we’re handling this correctly. But this is why we never skip dual verification. It’s not just policy—it protects lives.

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Nurse (senior)
(To patient)
Ms. Cho, we stopped the transfusion because you had a reaction. We’re treating it now, and you’re in safe hands. Don’t worry.

 

Patient
Did I get the wrong blood? Is this my fault somehow?

 

Nurse (senior)
No, you did nothing wrong. There was an issue with the verification process, but because you spoke up quickly, we were able to respond right away. We're taking all necessary steps to ensure your safety.

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Nurse (senior)
(EMR Documentation)
🗓 2025.04.13, 11:30 AM
• Transfusion started at 11:00, stopped at 11:10 due to reaction
• Patient developed chills, back pain, fever (38.5°C), and hypotension (BP 82/54) – suspected acute hemolytic transfusion reaction
• Transfusion stopped, IV normal saline initiated
• Blood bag and transfusion set preserved
• Doctor notified; labs ordered: CBC, Coombs, LDH, Bilirubin, Haptoglobin, Urinalysis
• Acetaminophen 500 mg IV administered; Hydrocortisone 100 mg IV prepared per physician order
• Blood bank and infection control team notified
• Transfusion Reaction Report completed
• Ongoing monitoring – SpO₂ stable at (90) percent

 

 

 

 

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✅ Key Learning Summary

 

Situation	Transfusion started after single-person verification → Acute hemolytic reaction within 10 minutes
Nursing Actions	① Immediate transfusion stop and saline maintenance ② Recheck vital signs and assess symptoms ③ Report to physician and initiate emergency labs ④ Preserve blood unit, transfusion set, and sample → send to blood bank ⑤ Administer antipyretic and Hydrocortisone as ordered ⑥ File Transfusion Reaction Incident Report and notify infection control
EMR Documentation	Record: transfusion start/stop time, symptoms, vitals, interventions, physician instructions, preserved materials, and all communications
Clinical Education Point	✅ Dual verification is a legal and safety-critical requirement ✅ Skipping this step can result in life-threatening reactions ✅ Immediate recognition, reporting, preservation, and intervention determine patient outcomes

 

 

👉 Catheter Management : CVC, PICC, and Implanted Port (Chemoport)

Catheter Management Scenarios: Central Venous Catheter (CVC), Peripherally Inserted Central Catheter (PICC), and Implanted Port

 

👉 Oxygen Therapy(Nasal prong, Mask, Nebulizer)

Applying a Nasal Prong for Oxygen Therapy

 

👉  Transfusion-10 possible Error 

Scenario 1. Crossmatch Completed, but Blood Bank Sent Mismatched Blood → Nurse Identifies Error During Dual Verification and H

Single-Person Blood and Patient Verification→ Acute Hemolytic Reaction Occurs → Full Emergency Protocol Activated