[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 1. Vital Signs Not Checked Before Transfusion → Acute Reaction Occurs, Emergency Response and Reporting Initiated
Patient Information
65-year-old male, diagnosis: Pneumonia and chronic heart failure (CHF)
Morning hemoglobin: (6.5) g/dL. Due to fatigue and hypoxia, 2 units of PRBC were prescribed.
Transfusion was started without pre-transfusion vital signs being measured. About 5 minutes later, the patient’s condition changed suddenly.
Nurse (new)
Mr. Jung, we’re going to start your first unit of PRBC now. I’m connecting the transfusion line.
Patient
Okay… I feel a bit thirsty. I hope everything will go well?
Nurse (new)
Yes, I’ll stay by your side and monitor you closely for the first 15 minutes.
(5 minutes after starting transfusion)
Patient
Ugh… I suddenly feel cold, and my lower back really hurts… I think my urine looked odd earlier, too…
Nurse (new)
Oh? You’re in pain? Your hands are shaking too... Nurse! I need help here!
Nurse (senior)
(Arriving at bedside urgently) Let me take your vital signs first.
BP (78/50) mmHg, HR (122) beats/min, Temp (38.4) degrees Celsius, RR (24) breaths/min, SpO₂ (91) percent.
Nurse (senior)
This could be an acute hemolytic reaction. Stop the transfusion immediately, and replace the IV line with a new one. Keep the blood bag intact. I’ll call the doctor now.
Nurse (senior)
(Calling Doctor Park)
Doctor Park, this is regarding Mr. Insoo Jung (ID: 20250413). About 5 minutes into PRBC transfusion, the patient developed chills, lower back pain, fever, and hypotension.
Vital signs: BP (78/50), HR (122), Temp (38.4). Pre-transfusion vital signs were not recorded. Transfusion was stopped immediately, and IV line replaced. We’re reporting this as a suspected transfusion reaction.
Doctor Park
Good response. Preserve the blood bag, and order CBC, Coombs test, LDH, bilirubin, and haptoglobin. I’ll send prescriptions for IV fluids and antipyretics now. Please prepare the transfusion reaction report as well.
Nurse (senior)
(EMR Nursing Note)
🗓 2025.04.13 10:10
• Patient developed chills, back pain, and fever during PRBC transfusion → Transfusion stopped immediately
• No pre-transfusion vital signs were documented
• Doctor notified, and emergency labs ordered (CBC, Coombs, LDH, etc.)
• Blood bag preserved for investigation
• Vital signs at time of reaction:
BP (78/50) mmHg, HR (122) bpm, Temp (38.4)°C, RR (24) breaths/min, SpO₂ (91)%
Nurse (senior)
(To patient)
Mr. Jung, we’ve stopped the transfusion due to a sudden reaction. We’re now running some tests using the blood product to ensure safety. Please don’t worry—we’re closely monitoring you.
Patient
Oh, so that’s why I felt chills… Am I going to be okay?
Nurse (senior)
Yes, because you told us how you felt early on, we were able to respond quickly. You’re in good hands, and we’ll make sure everything is safe moving forward.
Nurse (senior)
(To new nurse)
Vital signs must always be taken before starting any transfusion. They serve as the baseline to detect any changes. Without that, it’s hard to judge whether a reaction is occurring.
Nurse (new)
I’m really sorry… I was so focused on the setup that I completely forgot to check vitals…
Nurse (senior)
It’s okay. The important thing is that we caught it in time. But let’s make this a habit—always check and record baseline vitals before transfusion, no matter how busy things are.
Patient
I’m grateful you acted quickly. You all seem really reliable.
Nurse (senior)
Thank you, Mr. Jung. It’s because of you being honest about your symptoms that we handled this safely. We’ll stay right here with you for now.
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