Wrong Blood Component Connected (Different from Physician’s Order) → Error Detected Before Transfusion Begins

 

 

[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

Transfusion Procedure Phase – 10 Possible Error Cases

 

 

 

 

 

 

 

 

Scenario 8. Wrong Blood Component Connected (Different from Physician’s Order) → Error Detected Before Transfusion Begins

Patient Information
62-year-old male, diagnosed with acute anemia due to gastrointestinal bleeding
Hemoglobin: (6.1) g/dL, physician ordered 2 units of PRBC
Preparation underway for first unit

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Nurse (new)
Mr. Lee, I’m getting ready to start your blood transfusion.
(Prepares to connect the unit without checking label thoroughly)
The blood is now connected—ready to begin.

 

Nurse (senior)
(Glancing over) Wait, what product are you using?
(Holds up the blood bag) This is FFP (Fresh Frozen Plasma).
The order was for PRBC, not plasma.

 

Nurse (new)
Oh no… I just checked the number and assumed it matched. I didn’t check the actual product type.

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Nurse (senior)
Fortunately, we caught it before the transfusion started.
In this case, we must stop immediately, report to the doctor, and discard the FFP.
Wrong product transfusion can lead to hemolytic reactions, allergic responses, or ineffective treatment.

 

Nurse (new)
I’m so sorry… I didn’t realize how critical the differences are between blood components.

 

 

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Nurse (senior)
(Calling Doctor Han)
Doctor Han, for patient Jungmin Lee (Patient ID: 20250425), we discovered that FFP was accidentally connected instead of PRBC.
The error was identified before transfusion began during the double-check process.
We’ve stopped immediately, will discard the FFP, and have already requested a new PRBC unit.

 

Doctor Han
Thank you for the quick action. I’m glad it was caught in time.
Please document everything and make sure the patient is informed.

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Nurse (senior)
(To patient)
Mr. Lee, while preparing your transfusion, we discovered that the wrong product type (plasma) had been connected.
We identified the error before anything was infused and have stopped it immediately.
We’re now preparing the correct blood component for you—please rest assured, you are safe.

 

Patient
Oh wow… I could’ve gotten the wrong blood? I’m just glad you caught it. Thank you.

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Nurse (new)
(EMR Documentation)
🗓 April 14, 2025 – 2:30 PM
• During preparation for PRBC transfusion, FFP was mistakenly connected
• Error discovered during pre-transfusion double check → Transfusion halted before starting
• Doctor Han notified immediately; FFP to be discarded
• New PRBC unit requested; patient stable
• Vitals: BP (118/72) mmHg, HR (88) bpm, Temp (36.6)°C, RR (18)

 

 

 

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✅ Key Learning Summary

Situation	PRBC was ordered, but FFP (plasma) was mistakenly connected—caught before infusion
Nursing Actions	① Stop immediately ② Reconfirm blood product and label ③ Notify physician ④ Discard incorrect product and request correct unit ⑤ Inform patient and document in EMR
EMR Documentation	Include time of error detection, corrective actions, physician contact, vitals, and resupply status
Clinical Education Point	✅ Clearly distinguish blood products by label, color, and purpose ✅ Double nurse verification before transfusion is essential ✅ Wrong component transfusion poses serious patient safety risks

 

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

 

Applying a Nasal Prong for Oxygen Therapy

 

 

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

 

Wrong Blood Component Connected (Different from Physician’s Order) → Error Detected Before Transfusion Begins