Specimen Barcode Label Does Not Match Patient Information → Specimen Discarded, Recollection & Reporting Performed

 

 

 

[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

 

 

 

 

Scenario 5. Specimen Barcode Label Does Not Match Patient Information → Specimen Discarded, Recollection & Reporting Performed

 

Patient Information
65-year-old male, diagnosed with cirrhosis-related hemorrhagic anemia
Hb: (6.4) g/dL → PRBC 2 units ordered
Pre-transfusion testing (ABO, Rh, crossmatch) to be done via EDTA sample

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Nurse (primary)
Mr. Jung, I’ll begin by checking your wristband before drawing blood. Name: Gihoon Jung, Patient ID: 20230412, and no blood type recorded yet.

 

New nurse, do you have the EDTA tubes ready?

 

Nurse (new)
Yes, two 6 mL EDTA tubes prepared, and I’ve printed the barcode labels as well.
(as they prepare to apply the labels)

 

Nurse (primary)
Hold on. Let me see the labels first.
Hmm... this says Giwhan Jung, and the patient ID is 20230421.
That’s a different patient. Using this would be a serious error—it could lead to a critical medical incident.

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Nurse (primary)
We need to discard this specimen immediately.
I’ll report this to the attending doctor. We’ll perform a recollection. I’ll explain everything to the patient.

 

Nurse (primary)
Mr. Jung, the label printed for your blood sample had someone else’s information on it.
To protect your safety, we’re discarding the sample and recollecting. Thank you for understanding.

 

Patient
Another blood draw? That’s okay… I’m just glad you double-checked. Thank you for being careful.

 

 

 

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Nurse (primary)
(Calls Doctor Kim)
Doctor Kim, during pre-transfusion testing for Gihoon Jung (ID: 20230412),
we discovered that the barcode label printed by a new nurse contained another patient’s information.
The sample has been discarded, and recollection is underway. The patient was informed and agreed.

 

Doctor Kim
Thank you for catching that. Verifying barcodes before attachment is essential.
Please recollect and resubmit the specimen to the blood bank.

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Nurse (primary)
(Recollection steps performed)

1. Print new barcode label → double-check with patient wristband
2. Prepare two 6 mL EDTA tubes
3. At bedside, verify name and ID verbally with patient
4. Draw blood and attach correct labels immediately
5. Enter order in EMR and submit sample to lab

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Nurse (primary)
(To new nurse)
You must always double-check the barcode label against the patient’s wristband before attachment.
An error like this could lead to a wrong blood transfusion, which is potentially fatal.

 

Nurse (new)
I completely understand. I’ll make barcode verification part of my checklist routine moving forward.

 

Patient
You nurses are so thorough—it really helps me feel safe.

 

Nurse (primary)
Thank you, Mr. Jung. We’ll make sure everything is done right from here.

 

 

 

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Nurse (primary)
(EMR Documentation)
🗓 April 8, 2025 – 1:00 PM
• During pre-transfuion testing, barcode label was found to be mismatched with patient ID
• Specimen discarded, patient informed and consented to recollection
• Doctor and blood bank notified
• Vitals: BP (110/70) mmHg, HR (92) bpm, Temp (36.7)°C, RR (18) breaths/min, SpO₂ (97)%

 

 

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✅ Key Learning Summary

 

Situation	Barcode label printed for pre-transfusion specimen did not match patient information
Nursing Actions	① Discard the specimen immediately ② Notify physician and explain to patient ③ Reprint barcode and perform double-check before relabeling ④ Recollect blood sample ⑤ Resubmit to blood bank
EMR Documentation	Include time of error, recollection status, physician contact, vitals, and explanation to patient
Clinical Education Point	✅ Never attach labels without verifying patient ID ✅ Always confirm name and ID verbally before collection ✅ Specimen errors can lead directly to mismatched transfusions and serious harm

👉 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

Specimen Barcode Label Does Not Match Patient Information → Specimen Discarded, Recollection & Reporting Performed