A patient undergoing blood transfusion experienced an allergic reaction after the nurse failed to properly monitor his vital signs as required every 30 minutes. Transfusion reactions can be life-threatening if not properly monitored and treated. Nurses have a duty of care to patients under their care. By neglecting to monitor the patient's vital signs as ordered, the nurse breached their duty of care, which likely contributed to the patient's adverse reaction going unnoticed and untreated. Strengthening nursing home staff training and increasing minimum staffing requirements could help avoid such medical errors and improve patient safety and outcomes.

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Negligence (breach of duty of care)
Introduction
Negligence arising from medical act result in an action is by the injured party or a criminal
hearing by the state (Wessels, A. B,2019).Medical negligence is proved if all components of the
three-part test are established on the balance of probabilities or away from levelheaded
uncertainty (Deodhar, 2019). The three-part test establish that the nurse billed a duty of care to
the patient, the duty of care was breached, and as a direct result of the breach the patient suffered
damage (Babatunde, 2018).Successful actions result in pecuniary reimbursement to the injured
party or dependents which be salaried by the employ trust or the nurse's defense organization
(Gallegos, 2019).
Where a duty of care is breach, liability for negligence will arise. Medical negligence is part of a
branch of law called tort and derive from the Latin verb ‘tortere’=to hurt. The idea of hurt is an
important reflection in establishing negligence, as the preponderance of tortuous claim for
medical negligence that do not succeed fail because they cannot establish that harm has occur as
a direct outcome of an act.
The relationship between a nurse and a patient is a special one. When a patient is admitted to
hospital, a duty of care relationship is created, which be applied to any nurse coming into get in
touch with the patient not just the admit team. for this reason, it has been argued by medical law
academics that any patient come across in hospital setting is owed a duty of care, not only by the
nurse the patient comes into contact with, but also by those who are employed by the trust to
deliver patient care (Celik, 2017).Breach of duty establishes when nurse's practice has failed to
meet a suitable standard that is this situation not measuring the vital signs on time but she was

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busy that time with other patient because she was assign six patients to take care off at that time
(Bono, 2017).
Blood transfusion is like marriage, it should not be embark upon lightly, un-advisedly or more
often than is absolutely necessary ( Bielby, & Moss, 2018). As any treatment, though,
transfusion of blood and blood components must be order and administered safely and
appropriately (Franchini, et al 2019). Transfusion is more than a discrete event while it is a
process (Glasgow et al. 2018).
Challenges couple with the fact that, it is a form of transplant and associated with injurious
complications to blood donors and recipients, calls for a critical assessment particularly that,
some complications be predictable or potentially prevented at the same time as others may go
unnoticed only to present as blood transfusion injury ( Kaur et al. 2017). The risk associated with
this essential service and the need for great concern in blood transfusion practice has been
canvass by many workers. For that reason, one of the vital yet challenging responsibilities
hospitals in countries engage in is the provision of safe blood services. Medical practitioners who
order blood for their patients are faced with the challenge of managing the blood transfusion
process needs of the patient in an evidence base approach or balancing the expected clinical
benefit with the medical and legal risks intrinsic in the transfusion of blood (Garraud et al. 2018)
Making an allowance for that, as in many developing countries of the world as in our country in
this case, it is not unusual to go through a medical school without acquiring a sound knowledge
of medical ethics (Nemati et al.2019).
Feared grossly inadequate knowledge of medical ethics by medical practitioners, Joseph et al
(2018) and the view of blood transfusion in legal jurisprudence, as a professional service for

3. 3
which the actions of the practitioner should be viewed against that of a reasonable professional.
Medical practitioners who make fatal mistakes or are negligent at hospital base blood transfusion
services may be liable for professional negligence as neglecting the complication and not
properly monitoring the vital signs can lead the patient to the death (Garraud et al 2018).
Nurses are ideally placed to drive the safety and quality schema within health care because of
their unique propinquity to patients. There has been some attempt to look at the links between
nursing care and quality outcomes, but relatively little on the connection between nursing and
patient safety. Therefore, exploring the evidence on this issue was indicated, excluding links to
nurse staffing and environment.
Position statement
A patient Mr. X was post operatively care by a nurse in surgical unit, as his hemoglobin level
was lower as dangerous for his health, he was advised two pint of blood by his surgeon. His
blood was arranged and transfused and was given an order of half hourly vitals monitoring by
registered nurse on duty. His fist pint of blood was finished after two hours and vitals were
monitor only at the start of his transfusion and Mr. X starts sever shivering and body rashes after
half hours of blood transfusion. Breach of duty of care taken place by registered nurse on duty.
Situational Analysis
Transfusion reactions are unfavorable events connected with the transfusion of whole blood and
one of its components. They range in severity from minor to gravely events and can occur during
a transfusion, term as acute transfusion reaction, and days to weeks later, term as delay
transfusion reactions (Siddon et al, 218). Transfusion reactions may be difficult to diagnose as
they can present with non-specific, often overlapping symptoms. The most common signs and

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symptoms include fever, chills, urticaria, and itching and abnormal vital signs. Some symptoms
may resolve with little or no treatment. However, respiratory distress, high fever, hypotension,
and hemoglobin-urea lead to more serious reaction even causing death. All cases of suspected
reactions should prompt immediate discontinuation of the transfusion and notification of the
blood bank and treating clinician and all this is only possible while a professional is continuously
monitoring the patient’s vital signs. This activity reviews the evaluation and management of
transfusion reactions and highlights the role of inter-professional team members in collaborating
to provide well-coordinated care and enhance outcomes for affected patients and also for every
member to recognize his/her duties and follow the rules of organization. (Suddock & Crookston,
2020).As by name vital signs are most important for any procedures but procedure like causing
severe allergic reactions can lead to the death and any adverse complication by the negligence of
duty, breach of duty of care as in this case.
As knowing, diagnosis of acute transfusion reactions begins by recognition of the signs and
symptoms by the bedside and if nurse neglect the patient during blood transfusion silently
pushing the patient into dangerous events. Common signs and symptoms and differential
diagnosis are
Urticaria (hives) and/or itching can be the presenting sign of a mild allergic reaction, but can also
be associated with the onset of a life-threatening anaphylactic reaction. The transfusion should be
stopped, and the patient should be carefully monitored for progression of symptoms.
Fever and/or chills are most commonly associated with a febrile, non-hemolytic reaction,
however; they can also be the first sign of a more serious acute hemolytic reaction, or septic
transfusion reaction. If the temperature rises 1 C or higher from the temperature at the start of

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transfusion, the transfusion should be stopped. Acute hemolytic reaction or bacterial
contamination should be suspected if there is a greater rise in temperature, or more serious
symptoms (e.g., rigors).
Dyspnea, or shortness of breath, is a concerning sign that can often be seen with more severe
reaction like anaphylaxis. It can also be seen by itself without accompanying symptoms.
Hypotension can be seen with an acute hemolytic reaction, septic transfusion reactions,
anaphylaxis, and TRALI. They have also been reported without the presence of any other
associated transfusion reaction.
Hypothermia can be seen with large volume transfusions of refrigerated products. The only
intervention needed is warming the patient and/or blood product.
Being negligent is not the same as making a mistake or error of judgment. Even if a particular
risk eventuates, or a desired outcome is not achieved, this does not necessarily mean negligence
has occurred. This is particularly true in healthcare, as most medical interventions have risks and
complete safety can rarely be guaranteed (Law Handbook SA 2013b; QLD Law Handbook
2016).
Strategies and Leadership Model
Spiraling the Regulatory practice
Any ethical issue can arise in any healthcare situation where reflective moral questions of right
and wrong underlie qualified decision making and the care of patients. Health professional more
than ever nurses face ethical challenge in their daily practice as they are required to provide self
governing and shared care to individuals of all ages, while adhere to the ethical principles. The

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situation becomes particularly complex for nurses who work under severe resource constraint.
Furthermore due to the demographic, social, scientific and technological aspects of health care,
there has been an increase in involvedness of ethical issues faced in the health care service
delivery. Ethical issues in the nursing practice attract little attention, resulting in the creation of
moral distress, poor professional care, un-productivity and conflict.
The Pakistan Nursing Council (PNC) adopted its own professional code of ethics in 1999 for
registered nurses. The current study was undertaken to identify adherence of nurses to the
Pakistan Code of Professional Ethics, with an aim to improve patient care (Jafree et al., 2015). It
also explores the ethical issues faced by nurses in their clinical setting and how they work
through difficult cases. The study draws on thematic areas that are intrinsic to any clinical
encounter, namely: Medical Indications, Patient Preferences, Quality of Life, Contextual
Features, Teamwork and value of nursing profession. These issues were reviewed in light of the
professional ethical code prescribed by the Pakistan Nursing Council, inclusive of professional
accountability with reference to the clients, colleagues and one self. There must be strict follow
up and implementations of these laws.
Humanizing Information Systems for Quality care Monitoring
Legitimate, trustworthy, and timely documentation and vital monitoring about nursing competent
residents and the care they receive are fundamental to all strategies for monitoring and improving
quality of care. It is essential both to remote regulator and to individual providers. Key data
about all nursing home inhabitants are collecting as part of the federal-mandated minimum data
set (MDS). Originally designed for needs assessment and care planning, the MDS periodically
collects in sequence on resident functional and medical status. Since 1990, nursing homes have
been requiring to collect MDS data for every resident upon admission, as soon as there are major

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changes in health status, and at least annually. Since June 1998, all nursing homes have been
requiring to submit the MDS information electronically to CMS on a quarterly basis. Although
not developed as a quality assurance measure, MDS data are now also being used to construct
quantitative “quality indicators” on accidents, behavioral and emotional problems, cognitive
problems, incontinence, use of psychotropic drugs, pressure ulcers, physical manacles, weight
problems, and infections (Zimmerman et al., 1995). CMS uses these quality indicators as part of
the survey and certification process both to help measure quality and to identify specific
residents who may be receiving poor-quality care.
At least three concerns have been voiced about the use of MDS data for quality assurance
purposes. First, the data may not be accurate, especially now that it is being used for regulatory
purposes, as well as care planning. A key issue is that facility staff fills out the MDS. If CMS
uses this data to punish the facility, staff has incentives to alter reporting to avoid these negative
sanctions. However, a recent CMS-funded study bring into being good levels of reliability in
MDS-derive quality indicator, at least among the study facilities (Morris et al., 2002).
Second, quality indicators face difficult statistical issues. Some of the more serious quality
indicators, such as decubutis ulcers, do not involve very many residents, even in poor facilities.
Given the relatively small number of residents in nursing homes (the average facility only has
about 90 residents), random variation in the prevalence of pressure ulcers may be substantial. In
addition, case-mix adjustment may be crucial to properly identifying poor performers, but these
adjustments are quite complicated to perform, requiring Bayesian multilevel hierarchical
modeling (Angellilli, 2000). Failure to risk-adjust the measures would punish facilities that admit
more severely disabled and medically complex residents.

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Third, although, in theory, poor performance on the quality indicators is supposed to trigger
additional investigation to establish whether poor-quality care is actually provided, advocates,
researchers, and regulators may be inclined to take them, in and of themselves, as evidence of
poor-quality care. For example, CMS is starting a five-state pilot project to make 11 quality
indicators widely available to consumers with the explicit assumption that they measure quality
of care (U.S. Department of Health and Human Services, 2001). This may or may not be the
case. However, a recent CMS-sponsored study found a substantial number of quality indicators
to have a high degree of validity and a significant number of additional ones to have a good level
of validity (Morris et al., 2002). As mentioned previously, though, merely the absence of
negative outcomes still may not identify a facility in which we would want to live our lives.
Strengthening the Care giving Workforce
Nursing home care is a service that is provided by people, not machines. Three approaches have
been proposed to improve nursing home care by strengthening the care giving workforce. The
first strategy is to increase the amount of personnel in nursing homes by mandating higher
minimum staffing ratios. The second approach is to increase the required minimum training of
people who work in nursing homes, especially certified nurse assistants. The final mechanism is
to improve wages, benefits, and working conditions in nursing homes to attract and retain
“better,” more qualified staff.
Improving Staff schooling and Staff Ratios
Federal standards for staffing in nursing homes do not specify particular quantities of staff.
Although OBRA 87 requires that nursing facilities have licensed nurses on duty 24 hours a day,
an RN on duty at least 8 hours a day 7 days a week, and an RN Director of Nursing, these

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requirements are not adjusted for facility size or case-mix. Instead, the law requires that the
facility have “sufficient” staff to provide nursing and related services to attain or maintain the
“highest practicable level” of physical, mental, and psychosocial well-being of every resident.
But federal law and regulation do not provide specific standards or guidance as to what
constitutes “sufficient” staffing. The number of personnel per resident varies widely across
facilities. For example, in 1998, the median facility provided 3.21 hours per day of nursing time,
but the 10th percentile facility provided only 2.46 hours per day, and the 90th percentile facility
provided 4.66 hours per day (Harrington, Carillo, & Wellin, 2001). A recent CMS report to
Congress concluded that a majority of nursing facilities were understaffed (Health Care
Financing Administration, 2000).
A number of studies have found a positive association between nurse staffing levels (especially
for registered nurses), and the processes and outcomes of care (Institute of Medicine,
1996, 2001). For example, Harrington and colleagues (2000c) showed that higher nurse staffing
hours were associated with fewer nursing home deficiencies. Many reports of poor-quality care
(e.g., rushed eating and not answering call bells) would appear to be linked to inadequate staffing
levels.
Many clinicians, researchers, and consumer advocates consider the federal nursing home staffing
standards to be too vague and have called for higher, more specific standards. Based on expert
opinion, the National Citizens' Coalition for Nursing Home Reform (1995) and another expert
panel (Harrington, Kovner, Mezey et al., 2000b) have recommended minimum staffing at the
80th to 90th percentile of current staffing in nursing facilities (Institute of Medicine, 2001). A
new CMS report to Congress found “strong and compelling” statistical evidence that nursing
homes with a low ratio of nursing personnel to patients were more likely to provide substandard

10. 10
care, and the study authors recommended a minimum staffing ratio of 4.1 hours of care per day
(CMS, 2002).
The nursing home industry and many government officials oppose the imposition of higher and
more specific staffing requirements for several reasons. First, they argue that how staff are
organized, supervised, and motivated is at least as important as the number of workers. Merely
“throwing bodies” into a poorly run facility, they contend, will not improve quality of care.
Second, a major difficulty in setting standards is that there is little empirical, quantitative
research on what the minimal staffing level should be. Up until the recent CMS study, all of the
proposed standards rely solely on expert opinion and fail to adjust for case-mix, which is the
primary determinant of staffing needs. Third, depending on the minimum staffing level
established, additional costs could be significant. The recent CMS-sponsored study estimated the
incremental costs of its proposal at $7.6 billion a year, an 8% increase over current spending. In
part because of the costs involved, the Bush Administration does not plan on proposing
minimum staffing levels for nursing homes. Fourth, the current staffing shortage makes it
difficult to implement any initiative to mandate increased staffing levels (Stone & Wiener,
2001).
One possible reason for poor quality in nursing homes is that staff is not adequately trained.
Especially with the increased acuity of nursing home residents and the greater complexity of care
needed today, one strategy to improve quality of care is to significantly increase training
requirements for all types of nursing home staff.
Certified nurse assistants make up the largest proportion of caregiving personnel in nursing
homes and provide most of the direct care, but they receive little formal training. OBRA 87
requires nursing assistants to receive a minimum of 75 hours of entry-level training, to

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participate in 12 hours of inservice training per year, and to pass a competency examination
within 4 months of employment. Some states, such as California, require longer periods of
training (Harrington, Kovner, Mezey, et al., 2000b). As minimal as the training requirements are,
they exceed what most other low-skill, low-paid jobs require, and may deter some people from
working in the industry. On the other hand, the minimal training also means that there is no
career ladder for certified nurse assistants.
There are three major issues involving staff training requirements. First, although there is logic to
formal minimum training requirements, there is no research on what those levels should be and
what the impact of increased training has on quality of care. Second, training is not free. The
facility, the worker, or some third party must pay for it. Third, higher training requirements may
exacerbate the staffing shortage by making it more difficult to work in nursing home settings.
Wages, Benefits, and Working Conditions
Although cyclical economic conditions significantly affect demand for paraprofessional workers,
low wages and benefits (along with difficult working conditions and heavy workloads) make
recruitment and retention of nursing aides difficult, even when unemployment rates are high
(Stone & Wiener, 2001). Difficulty in recruiting aides is likely to worsen over time as the
number of people needing long-term care increases more quickly than the working age
population.
Nursing home workers, especially nurse assistants, receive low wages and generally lack fringe
benefits. According to the Bureau of Labor Statistics, the median hourly wage for nursing aides
in 2000 was $8.61 (Bureau of Labor Statistics, 2002). Using pooled Current Population Surveys
from 1995 and 1997, Leavitt (1998) found the median yearly earnings for nursing home aides to

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be only $11,000. Besides earning low wages, these workers also receive few fringe benefits, such
as health insurance and pension coverage (Crown, Ahlburg, & MacAdam, 1995).
Higher real wages and benefits for nursing assistants should help draw more marginal workers
into the labor force. Moreover, increases in the relative compensation for nursing home staff
could help reallocate available low-wage workers to the long-term care sector. Elasticity of labor
supply across occupations with few education and training requirements are relatively high
(Ehrenberg & Smith, 1997). And the numbers of workers who might be available for such shifts
are substantial. Obviously, providing higher wages and benefits could also provide a better life
for workers. In recent years, several states have passed wage-pass through in their Medicaid
reimbursement rates requiring that higher payments be passed on to workers (Stone & Wiener,
2001).
Raising wages faces three difficulties, although they are not technically insurmountable. They
are more a problem of political will. First, although it is always difficult to increase government
spending, the recent recession, federal and state tax cuts, and the aftermath of the terrorist attacks
of September 11th make it especially difficult now. Many states are considering reimbursement
cuts rather than increases (Johnson, 2002). Second, making sure that reimbursement increases
result in wage and benefit increases is not always easy to verify, although increased regulatory
oversight could solve this problem. Third, no empirical research confirms that increased wages
and benefits result in improved recruitment and retention or have an impact on quality of care.
Thus, although there is a strong logic in favor of increased wages, policy makers do not have
confidence that the impact of higher wages will be worth the cost.
Increasing Medicare and Medicaid Reimbursements

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As noted previously, approximately three quarters of nursing home residents depend on
Medicaid and Medicare to pay for their care (American Health Care Association, 2001). The
reimbursement policies of these two programs are, therefore, critical to the level of resources
available to nursing homes. Medicaid and Medicare nursing home reimbursement policy is
particularly important as a policy lever, because federal and state officials have great control
over both the level and methodology of payment.
Two recent developments have directed new attention to the relationship between reimbursement
and quality of long-term care. First, the federal Balanced Budget Act of 1997 repealed federal
minimum standards for nursing home reimbursement (the Boren amendment), giving states
virtually unlimited freedom in setting nursing home payment rates. The nursing home industry
has warned that Medicaid reimbursement rates are already too low and that further reductions
would adversely affect the quality of care. Second, the Balanced Budget Act of 1997 established
a new prospective payment system for Medicare skilled nursing facility care that has adversely
affected a substantial portion of the nursing home industry (Childs, 2000). Nursing home
bankruptcies have raised concern that quality of care may deteriorate in these facilities.
There are two major issues with raising Medicare and Medicaid reimbursement rates. First, the
relationship between reimbursement levels and quality of care is not simple, and it is not clear
that higher reimbursement rates will improve quality of care. Although research in this area is
limited and rather old, some studies have found that higher reimbursement is associated with
more staffing, but failed to find a significant relationship to other measures of quality (Cohen &
Spector, 1996; Nyman, 1988).
Second, higher Medicare and Medicaid reimbursement levels obviously add to public costs.
Thus, the dilemma for policy makers is that a dollar's worth of increased reimbursement does not

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yield a dollar's worth of quality improvement. Higher rates are diluted in a number of ways—
including higher administrative expenses, profits, and inefficiency—that do not improve resident
outcomes.
Improving leadership qualities in organization
Leadership styles play an integral role in enhancing quality measures in health care and nursing.
Impact on health-related outcomes differs according to the different leadership styles, while they
may broaden or close the existing gap in health care. Addressing the leadership gap in health
care in an evolving and challenging environment constitutes the current and future goal of all
societies. Health care organizations need to ensure technical and professional expertise, build
capacity, and organizational culture, and balance leadership priorities and existing skills in order
to improve quality indicators in health care and move a step forward. Interpretation of the current
review’s outcomes and translation of the main messages into implementation practices in health
care and nursing settings is strongly suggested. Reflective practice has many parallels to
emotional intelligence. Reflective practice is the ability to examine actions and experiences with
the outcome of developing practice and enhancing clinical knowledge (Caldwell & Grobbel,
2013). According to the College of Nurses of Ontario (2015), reflective practice benefits not only
the nurse, but the clients as well. For the nurse, reflective practice improves critical thinking;
optimizes nurse empowerment; provides for greater self-awareness; and potentiates personal and
professional growth. For the client, reflective practice improves client quality of care and client
outcomes (College of Nurses of Ontario, 2015).
Conclusion and Recommendation

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It is also apt that, the indications and the planned transfusion including all issues relating to the
blood transfusion and vital signs monitoring must be recorded in the patients` hospital case file
and also monitoring patient closely for any reactions, also kept in safe keeping for a particular
period of time as the law require for the land. In the absence of such laws in Pakistan, these
records should be kept for 30 years as it is done in some developed countries like France as these
may avert possible blood transfusion related litigations.
On the other hand it must be realized that, it is through the lessons of our everyday errors that we
can design our work environment to be less error prone and more error tolerant. For that reason,
litigations due to blood transfusion injuries may appear punitive attracting damages to the liable
medical practitioner but, could also help strengthen blood bank practices and ensure safer blood
supplies for the communities particularly at hospital-based transfusion centers. Finally, the
implementation of a compulsory insurance policy for medical practitioners though expensive
remains the best approach for medical practitioners in the event that, there are proven medical
negligence charges to be indemnified. Implementation of evidence‐based interventions is crucial
to professional nursing and the quality and safety of patient care.
References
Wessels, A. B. (2019). The expansion of the state’s liability for harm arising from medical
malpractice: Underlying reasons, deleterious consequences and potential reform. Journal of
South African Law/Tydskrif vir die Suid-Afrikaanse Reg, 2019(1), 1-24.
Bryden, D., & Storey, I. (2011). Duty of care and medical negligence. Continuing Education in
Anaesthesia, Critical Care & Pain, 11(4), 124-127.

16. 16
Deodhar, R. P. (2019). Common Law and Indian Cases on Medical Negligence. Available at
SSRN 3350915.
Gallegos, B. C. (2019). A More Balanced Prescription: Reconciling Medical Malpractice Reform
with Fundamental Principles of Tort Law. Gonz. L. Rev., 55, 105.
Celik, G. O. (2017). The relationship between patient satisfaction and emotional intelligence
skills of nurses working in surgical clinics. Patient preference and adherence, 11, 1363.
Bono, M. J., Wermuth, H. R., & Hipskind, J. E. (2017). Medical malpractice.
Bielby, L., & Moss, R. L. (2018). Patient blood management and the importance of the
transfusion practitioner role to embed this into practice. Transfusion Medicine, 28(2), 98-106.
Franchini, M., Marano, G., Veropalumbo, E., Masiello, F., Pati, I., Candura, F., ... & Liumbruno,
G. M. (2019). Patient Blood Management: a revolutionary approach to transfusion
medicine. Blood Transfusion, 17(3), 191.
Glasgow, S. M., Perkins, Z. B., Tai, N. R., Brohi, K., & Vasilakis, C. (2018). Development of a
discrete event simulation model for evaluating strategies of red blood cell provision following
mass casualty events. European Journal of Operational Research, 270(1), 362-374.
Kaur, D., Bains, L., Kandwal, M., & Parmar, I. (2017). Erythrocyte alloimmunization and
autoimmunization among blood donors and recipients visiting a tertiary care hospital. Journal of
clinical and diagnostic research: JCDR, 11(3), EC12.
Garraud, O., Sut, C., Haddad, A., Tariket, S., Aloui, C., Laradi, S., ... & Andreu, G. (2018).
Transfusion-associated hazards: a revisit of their presentation. Transfusion Clinique et
Biologique, 25(2), 118-135.

17. 17
Siddon, A. J., Kenney, B. C., Hendrickson, J. E., & Tormey, C. A. (2018). Delayed haemolytic
and serologic transfusion reactions: pathophysiology, treatment and prevention. Current opinion
in hematology, 25(6), 459-467.
Garraud, O., Cognasse, F., Laradi, S., Hamzeh-Cognasse, H., Peyrard, T., Tissot, J. D., &
Fontana, S. (2018). How to mitigate the risk of inducing transfusion-associated adverse
reactions. Transfusion Clinique et Biologique, 25(4), 262-268.
Suddock, J. T., & Crookston, K. P. (2020). Transfusion reactions. StatPearls [Internet].
Jafree, S. R., Zakar, R., Fischer, F., & Zakar, M. Z. (2015). Ethical violations in the clinical
setting: the hidden curriculum learning experience of Pakistani nurses. BMC medical
ethics, 16(1), 1-11.