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Blood Transfusion. Review of Events. 2 units of PRBCs were checked at the nursing station by the RN and nursing assistant. Each pink slip was signed immediately after checking the respective unit of blood. Review of Events. RN placed the pink slips on the respective units of blood.
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Review of Events • 2 units of PRBCs were checked at the nursing station by the RN and nursing assistant. • Each pink slip was signed immediately after checking the respective unit of blood.
Review of Events • RN placed the pink slips on the respective units of blood. • The PRBCs were placed side by side on the desk. • RN went to the med room to get the blood tubing.
Review of Events • The RN picked up one unit of blood and the wrong pink slip. • The RN checked the pink slip and not the unit of blood when the transfusion was commenced. • Typenex bands were not checked in the patient’s room.
Review of Events • The correct pink slips were in the patient’s room • Current typenex bands were present in the patient’s rooms. • The error was detected when one of the patients started chilling one hour into the transfusion. • Each patient received ~ 150 cc of the wrong blood.
