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Difficulty: HardAccident, Error, and Injury Prevention

A registered nurse is managing the care of multiple clients on a medical-surgical unit and is preparing to initiate a transfusion of packed red blood cells (PRBCs) for a client with severe symptomatic anemia. Which actions by the nurse demonstrate correct safety principles to prevent administration errors and client injury? Select all that apply.

  1. Verify the client's two identifiers, blood type, and the unit identification numbers with a second registered nurse directly at the bedside.Answer
  2. B
    Delegate baseline vital signs and monitoring during the first 15 minutes of the transfusion to the unlicensed assistive personnel.
  3. Prepare the blood administration set using dedicated Y-type tubing with an in-line filter and prime it exclusively with 0.9% sodium chloride.Answer
  4. D
    Prioritize initiating the blood transfusion over assessing another assigned client who is reporting sudden, severe chest pain.
  5. Remain continuously present at the client's bedside for the first 15 minutes of the transfusion to monitor for early signs of an adverse reaction.Answer
  6. F
    Piggyback the blood product into a continuously infusing intravenous line of lactated Ringer's solution to maintain adequate hydration.

Answer

The correct safety interventions to prevent injury during blood administration are verifying identifiers with a second registered nurse at the bedside, using dedicated Y-type tubing primed only with 0.9% sodium chloride, and remaining at the bedside for the first 15 minutes.
Administering blood products requires meticulous safety protocols to prevent catastrophic errors. Verifying the client's identity and blood product details with a second RN at the bedside ensures the correct blood is given to the correct client. Using dedicated Y-tubing primed exclusively with 0.9% sodium chloride prevents hemolysis and clotting within the line. Remaining at the bedside for the first 15 minutes is crucial because severe, life-threatening transfusion reactions typically occur within this initial timeframe, requiring immediate nursing intervention.

Step-by-Step Solution

1
Identify the critical safety checkpoints for blood administration.
The nurse must verify identifiers with a second RN, use compatible fluids (0.9% sodium chloride), and perform continuous close monitoring initially.
Blood transfusions carry a high risk for fatal adverse events, such as acute hemolytic reactions, if safety protocols are bypassed.
2
Evaluate delegation and prioritization principles within the scenario.
The RN must not delegate the initial 15-minute assessment to unlicensed assistive personnel, and life-threatening symptoms (chest pain) in other clients take precedence over starting a routine transfusion.
The RN is strictly responsible for complex clinical judgments, and addressing airway, breathing, or circulation emergencies is always the highest priority.
3
Select all interventions that align with these established safety and error prevention standards.
Verifying identifiers with a second RN, using 0.9% sodium chloride, and staying with the client for the first 15 minutes are the correct actions.
These specific actions directly prevent administration errors, intravenous incompatibility, and delayed recognition of severe transfusion reactions.

Key Concept

Safe administration of blood products requires strict adherence to verification protocols, use of compatible IV fluids (only 0.9% sodium chloride), direct RN monitoring during the critical first 15 minutes, and appropriate clinical prioritization.
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Topics

Accident, Error, and Injury Prevention

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