Blood transfusion: bedside checks, monitoring and reactions
- Procedure
Two clinicians check the patient and the unit at the bedside, baseline vitals are taken, and the patient is watched closely for the first 15 minutes.
What it is
Most preventable severe transfusion reactions start with an identification error: the right unit in the wrong patient. The nurse is the last check before that error. That is why the check is done by two people at the bedside, with the order, the unit label and the patient in view. In Colombia, adverse transfusion reactions are reported to the haemovigilance network of the National Institute of Health (SIHEVI-INS).
Indications
- A provider's order for the component indicated (red cells, platelets, plasma, cryoprecipitate).
- Blood loss or anaemia the provider decides to correct.
- Clotting or platelet disorders, depending on the component.
- Always with signed informed consent and a current compatibility test.
Contraindications and precautions
- Without signed consent or a current compatibility sample (usually from the last 72 hours), do not start.
- Refusal for religious or personal beliefs: respect it and follow the institutional policy.
- Heart failure: higher risk of circulatory overload; the rate is set by the order.
- Do not keep blood in ward refrigerators or warm it in a microwave or hot water; do not shake it.
- Transfusion is not delegated to unlicensed assistive staff, although they may take vital signs in stable patients.
Equipment
- Blood administration set with a filter.
- 0.9 % saline to prime and keep the line open.
- Patent venous access: gauge 20 to 24 in general; 18 to 20 if it must run fast.
- Vital-signs equipment, the transfusion form and gloves.
Step by step (and why)
- Check the order, consent, history of reactions and compatibility test — without them there is no transfusion.
- Confirm a patent line and prime the filtered set with 0.9 % saline — it is the only compatible solution.
- Take baseline vitals; above 37.8 °C, call before starting — so a reaction can be told apart from the baseline.
- At the bedside, two clinicians confirm identity with two identifiers against the order and label — prevents the worst error.
- Compare group and Rh, unit number, expiry and appearance; if anything differs, do not start and call the blood bank.
- Start within 30 minutes of receiving the unit, slowly — so an early reaction exposes the patient to little blood.
- Stay with the patient for the first 15 minutes and take vitals at 15 — severe reactions appear then.
- Adjust the rate per the order and finish in under 4 hours — limits the risk of bacterial contamination.
- If you suspect a reaction: stop, keep the line open with saline through new tubing, stay with the patient and call.
- Return the bag and tubing to the blood bank, take the ordered samples and document — so the reaction can be studied and reported.
Transfusion reactions: when and how they appear
| Reaction | When | Signs |
|---|---|---|
| Acute haemolytic (ABO or Rh incompatibility) | Within the first 15 minutes | Low back, flank or chest pain, chills, fever, hypotension, breathlessness, dark urine |
| Febrile non-haemolytic | 30 minutes to 6 hours after the start | Rise of more than 1 °C over baseline, chills, flushing, headache |
| Allergic or anaphylactic | Allergic: during or up to 24 hours after; anaphylaxis: in the first minutes | Itching, hives, flushing; in anaphylaxis, wheeze, breathlessness, hypotension and loss of consciousness |
| Circulatory overload (TACO) | During or in the next 1 to 2 hours | Breathlessness, cough, crackles, tachycardia, hypertension, jugular venous distension |
| Acute lung injury (TRALI) | During or in the following hours | Breathlessness, hypoxaemia, cyanosis, fever, hypotension, non-cardiogenic pulmonary oedema |
| Septic (contaminated unit) | During or in the following hours | High fever, hypotension, chills, low back pain, nausea, vomiting, diarrhoea |
Complications
- An acute haemolytic reaction is almost always due to an identification or administration error, and it is preventable.
- TACO and TRALI look alike (both cause breathing difficulty); TACO usually comes with hypertension and TRALI with hypotension.
- In the INS 2023 national report, 90.6 % of reported reactions were non-severe, and the most common was allergic.
- In that report, TRALI and TACO were common among the reactions that threatened life or caused death.
- WHO notes that unnecessary transfusions and unsafe practices expose patients to severe reactions.
Next step: when to call for help
- Stop the transfusion and call at once for chills, fever, low back or chest pain, hives, breathlessness, hypotension or dark urine.
- Severe breathing difficulty, wheeze or loss of consciousness: call the rapid response or the ward's emergency code.
- Tell the blood bank about every reaction and any discrepancy in the check.
- Document the reaction and report it through the institution's haemovigilance programme.
Test yourself
Think of the answer, then tap the question to see it.
What do two clinicians check at the bedside before a transfusion?
The patient's identity with two identifiers against the order and the label, the ABO group and Rh, the unit number, the expiry date and the appearance of the blood.
Why do you stay with the patient for the first 15 minutes of a transfusion?
Because severe reactions, such as acute haemolysis and anaphylaxis, usually appear in that window.
What does the nurse do first when a transfusion reaction is suspected?
Stops the transfusion, keeps the line open with saline through new tubing, stays with the patient and calls the provider and the blood bank.
Which solution is the only one compatible with red cells?
0.9 % saline. No medications or other solutions are given through the same line.
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Nursing Advanced Skills, 3.2 Administer Blood Products: Basic Concepts (Open RN (Chippewa Valley Technical College), LibreTexts, 2023); Nursing Advanced Skills, 3.3 Administer Blood Products: Applying the Nursing Process (Open RN (Chippewa Valley Technical College), LibreTexts, 2023); Informe Nacional de la Actividad Transfusional en Colombia 2023 (Instituto Nacional de Salud (Colombia), 2024); Blood safety and availability (fact sheet) (World Health Organization, 2026).
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Representative model, for educational purposes only.