Blood Transfusion Verification Initiation and Reaction Response
Key Points
- Transfusion safety starts with strict compatibility verification and two-clinician check protocol.
- Blood administration requires dedicated blood tubing with filter and correct priming setup.
- Early recognition of transfusion reactions is a time-critical nursing responsibility.
- Suspected reaction requires immediate stop-transfusion response and escalation.
Equipment
- Provider order, transfusion consent, and blood-bank documentation
- Blood product with complete label data and compatibility verification materials
- Dedicated blood tubing with filter and normal saline prime/flush setup per policy
- Vital-sign monitoring equipment and emergency-response resources
- Documentation and incident/escalation workflow tools
Procedure Steps
- Verify order, indication, consent, and patient identity before obtaining blood product.
- At bedside, complete two-clinician verification of patient and product identifiers.
- Confirm product type, compatibility (ABO/Rh/crossmatch details), serial number, and expiration.
- Use only approved blood tubing/filter and prime per policy.
- Obtain baseline assessment and vital signs before starting transfusion.
- Start transfusion at ordered initial rate and remain with patient during early monitoring window.
- Reassess vitals/symptoms at required intervals and document response throughout infusion.
- Complete product documentation (type, volume, times, verification details, patient response).
- If reaction suspected, stop transfusion immediately, maintain IV patency with normal saline per policy, notify provider and blood bank, and follow reaction protocol.
- Continue close reassessment and complete all required reaction reporting/documentation.
Common Errors
- Incomplete bedside verification → life-threatening incompatibility risk.
- Wrong tubing setup or missing filter → clot/particulate safety risk.
- Delayed action on early symptoms (fever, dyspnea, rash, hypotension) → escalation to severe reaction.
- Inadequate documentation of verification and reaction details → unsafe continuity and legal risk.
Related
- peripheral-iv-access - Appropriate vascular access and line assessment before transfusion.
- intravenous-medication-administration-safety - Shared infusion verification and monitoring discipline.
- fluid-volume-overload-hypervolemia - Circulatory overload recognition during blood administration.
- medication-error-reporting-and-escalation - Structured escalation pathway for adverse transfusion events.
- blood-borne-pathogens - Infection-control context for blood-product handling.