Ensuring Blood Transfusion Safety: Preventing Errors and Sentinel Events

Authors

Brooklyn Lemaster

Files

Description

During my time working across various units at Hospital A, I frequently observed blood transfusions as a common procedure. One particular event stands out: a sentinel event in which the incorrect blood products were administered to a patient. This incident resulted in the patient exhibiting visible body tremors, dizziness, confusion, tachycardia, and hypertension. While the patient and blood product ID numbers were correctly matched, the error occurred when two type and screen results were switched in the blood bank. Fortunately, my nurse and I promptly reassessed the situation and stopped the transfusion. However, had we not intervened quickly, this simple mistake could have led to serious bodily harm or even death. The objective of this project is to prevent such "never events" from happening in the future. By prioritizing patient safety and harm prevention, this aligns directly with the core values of Quality and Safety Education for Nurses (QSEN). Through the application of QSEN principles, we aim to improve our transfusion processes, ensuring these errors never happen again and safeguarding our patients’ well-being.

Publication Date

4-16-2025

Disciplines

Higher Education | Scholarship of Teaching and Learning

Recommended Citation

Lemaster, Brooklyn, "Ensuring Blood Transfusion Safety: Preventing Errors and Sentinel Events" (2025). 2025 Celebration of Student Scholarship - Poster Presentations. 19.
https://scholarworks.moreheadstate.edu/celebration_posters_2025/19