m ABO blood group system was discovered by Karl

Landsteiner in 1900. 46 year later (1946) the Blood

Transfusion Service was formed.
m As blood transfusion is very common now a days.
However one mistake can cause many problems
ranging from minor to major like fever to cardiac
arrest.
r  year old young male admitted in ICU with road
traffic accident.
r On ventilator and hemodynamic ally stable.
r Ordered for blood transfusion as Hb was low.
r By mistake another patientǯs blood transfused to
him.
r Suddenly, blood transfusion reaction started.
r Patient end up into cardiac arrest which lead to
death .
r The purposes for presenting this case :
r Young male who was about to get marry in couple of
months , lost his life only because of nurse negligancy.
r The blunder was that, nurse did not check patientǯs
blood at bedside along with patientǯs I.D band and she
transfused another patientǯs blood to him.
r Ultimately patient died.
r Along with his death, his fiancée and family dreams
shattered.
r Neither she save his life nor she fulfill his dreams.
rBlood transfusion is the transfer of
blood or blood components from one
individual (donor) to another
(recipient). WHO ,007
rIf blood components are mistakenly
administered to the wrong patient it
produce hypersensitivity (Reaction).
 ï

ALLERGIC URTICA
FLUSHING
REACTION ITCHING

HEMOLYTIC FEVER
TACHYPNIC TACHYCARDIA
REACTION CHILLS

ANAPHYLAC CARDIAC
TIC CYNOSIS, ARREST
REACTION WHEEZING AND
SHOCK
 . Itis the responsibility of ›


 ›



 ›




 

 ›




›
›  blood products. All blood
and blood products must be checked by 

prior
to administration
 All patients having blood transfusions must have an
identification wrist band in place which includes patient's
first name, surname, date of birth and unit record number.
 Name and contact details of the requesting doctor .
 Number of units and type of blood product required.
 Any special requirements such as irradiation or leukocyte
depletion (if appropriate)
http://www.rch.org.au/policy_rch/?doc_id=1004&print=yes
(3 of 6)9/09/006
Modified policy of AKUH in June, 008.
 Registered nurses may administer blood only upon
issuance of physicianǯs order.
 Ensure that physician/registered nurse take consent
for blood transfusion.
 Ensure that blood has been typed and cross matched.
 Perform the following checks with the physician or
another nurse/LHV/MW/technician, verify following
data:
Patientǯs name
Patientǯs MR#
Type of blood product
Expiry date
Patient Ǯs and donorǯs blood group.
(A,B,AB or O).
6




›
›
  .
6


›

›

›

 
›



›
 ›
m After evaluating this sentimental event , we
analyze that due to staff negligancy the
crime was commit ed.
m Nurses being responsible for the final
bedside check before transfusion, have the
final opportunity to prevent a mis-
transfusion.
Transfusion of
blood saves life. An
error in blood
transfusion, at the
same time, takes
life.
m Carven,F.R&Hirancle,J.C.(007).±





 

±


 
   
 
,pp.1104-1017.
m T.C.(008).Immunological of Blood Transfusion
10(3),pp.11-16.