What to do in case of a blood transfusion to the wrong patient?

Management of Blood Transfusion to the Wrong Patient

If a blood transfusion has been given to the wrong patient, immediately stop the transfusion, monitor the patient for signs of a transfusion reaction, and contact the transfusion laboratory immediately. 1

Immediate Actions

1. Stop the transfusion immediately if you discover a wrong blood transfusion
2. Maintain IV access but switch to normal saline
3. Monitor vital signs closely (heart rate, blood pressure, temperature, respiratory rate)
4. Contact the transfusion laboratory immediately to report the incident
5. Observe for signs of transfusion reaction including:
   • Tachycardia
   • Rash
   • Breathlessness
   • Hypotension
   • Fever

Clinical Management

For patients showing signs of a transfusion reaction:

• Administer antihistamines or steroids for mild to moderate reactions
• Administer intramuscular/intravenous adrenaline if the reaction is life-threatening 1
• Collect blood samples for:
  • Complete blood count
  • Coagulation studies
  • Direct antiglobulin test
  • Repeat blood typing
  • Serum for potential hemolysis evaluation

For all patients (even without immediate reaction):

• Continue close monitoring for at least 12 hours after the incident
• Check renal function to monitor for delayed hemolytic reactions
• Maintain adequate hydration to protect renal function
• Document all observations and interventions thoroughly

Reporting and Documentation

1. Document the incident thoroughly in the patient's medical record
2. Complete an incident report according to local policy
3. Preserve all transfusion materials including:
   • Blood bag
   • Compatibility labels
   • Administration sets
   • Patient identification wristband
4. Report to hemovigilance system as this is a serious adverse event 2

Root Cause Analysis

Most wrong blood transfusions occur due to:

• Failure of final identity checks between patient and blood component
• Sample collection errors (wrong patient)
• Mislabeled samples
• Blood requests for the wrong patient 3, 4

Prevention Strategies

To prevent future incidents:

• Ensure all staff involved in transfusion are properly trained and competency-assessed
• Implement electronic transfusion systems where available 5
• Follow proper patient identification protocols using four core identifiers:
  • First name
  • Last name
  • Date of birth
  • Patient identification number 1
• Perform independent verification checks at the bedside before transfusion

Common Pitfalls to Avoid

• Don't assume that a patient without immediate symptoms is safe - delayed reactions can occur
• Don't discard the blood bag or transfusion equipment - preserve for investigation
• Don't delay reporting the incident to the transfusion laboratory
• Don't continue with the transfusion even if the patient appears stable
• Don't underestimate the seriousness of the event - wrong blood transfusion is potentially fatal 6

Remember that administering the wrong blood type is the most serious outcome of blood transfusion, with the risk of ABO incompatibility potentially leading to significant morbidity and mortality. Prompt recognition and management are essential to minimize harm to the patient.