# Situation: A 59-year-old woman on post-operative day 1 after a bowel resection develops fever, back pain, and hypotension 15 minutes into a transfusion of packed red blood cells, and she dies the next day. The unit had been crossmatched for another client in the same four-bed room. The hospital's patient safety committee reviews the event. Two days after the death, the family asks the attending physician and the head nurse what happened. The review is still under way. Which response BEST follows the hospital's disclosure policy?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629864  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 59-year-old woman on post-operative day 1 after a bowel resection develops fever, back pain, and hypotension 15 minutes into a transfusion of packed red blood cells, and she dies the next day. The unit had been crossmatched for another client in the same four-bed room. The hospital's patient safety committee reviews the event.

Two days after the death, the family asks the attending physician and the head nurse what happened. The review is still under way. Which response BEST follows the hospital's disclosure policy?

## 보기

1. Explain that fever and hypotension can follow any transfusion without error
2. Refer all of the family's questions to the hospital's legal counsel first
3. Share the facts known so far, apologize, and describe the review under way **✔ 정답**
4. Wait until the root cause analysis is complete before telling the family anything

**정답: 3**

## 해설

Clients and families have a right to honest information about harm from care. The responsible team discloses promptly per policy: the facts known so far, an apology or expression of regret as policy allows, and the steps being taken; disclosure does not wait for the full review. Calling a wrong-patient transfusion an unavoidable complication is untruthful, and routing every question to legal counsel denies the family honest information.

## 심화 해설

Honest disclosure of what is known now
This client died after a wrong-patient transfusion: the unit given to her had been crossmatched for another client in the same room. Two days later, while the review is still under way, the family asks what happened. Disclosure policy calls for the responsible team to share the facts known so far, to apologize or express regret as policy allows, and to describe the review that is under way. This response respects the family's right to honest information and the principle of veracity, without speculating about conclusions the review has not yet reached.

Why disclosure does not wait
Clients and families have a right to truthful information about harm that results from care. Delaying until the root cause analysis is complete leaves the family without answers for weeks and can look like concealment, which damages trust and often increases conflict. Disclosure is a process: the team tells the family what is known now, explains what is being done to find out more, and commits to updating them as the review progresses. Facts are shared, but blame and speculation about individual staff are avoided.

| Response | Problem |
| --- | --- |
| Say fever and hypotension can follow any transfusion | Untruthful: the reaction followed a wrong-patient transfusion |
| Refer all questions to legal counsel | Deflects and denies honest information |
| Wait until the root cause analysis is complete | Delays disclosure the family is entitled to now |
| Share known facts, apologize, describe the review | Correct |

Why the other responses are wrong
Describing the event as a complication that can follow any transfusion is misleading; it presents a preventable error as unavoidable and violates veracity. Legal counsel may advise the team on how to disclose, but routing every question to the lawyer denies the family the honest communication they are owed. Waiting for the complete analysis before telling the family anything confuses disclosure with the final report; the two are separate, and disclosure begins promptly.

Watch out! Disclosure is a team responsibility led by the attending physician with nursing participation, according to the hospital's policy. A nurse should not offer guesses or assign blame, but should never deny or minimize what is known.

Exam takeaway
Key point! After an adverse event, disclose promptly: share the known facts, express regret, explain the steps being taken, and promise updates. Incident reporting and the root cause analysis continue in parallel, and the focus of the review is on systems, such as patient identification at the bedside, rather than individual blame.

## 임상 시나리오

Disclosure After a Transfusion ErrorHonest communication while the review continues
After harm from care, the team discloses promptly: the facts known so far, an apology or expression of regret as policy allows, and the review that is under way.

Disclosure does not wait for the root cause analysis. The family is updated as the review proceeds.

Calling a wrong-patient transfusion an unavoidable complication is untruthful, and sending every question to legal counsel denies honest information.

CautionShare facts, not speculation or blame; the review focuses on systems such as bedside patient identification.

## 핵심 개념

- **Disclosure** — Honest communication to a client or family about an adverse event, its known causes, and the steps being taken.
- **Veracity** — The ethical duty to tell the truth and not deceive clients or families.
- **Root cause analysis** — A structured review of an adverse event to find system causes and prevent recurrence.
- **Wrong-patient transfusion** — Transfusion of blood crossmatched for another person, often caused by identification failure.

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