Experience of mismatched blood transfusion for an rh negative patient and reconsideration of emergency blood transfusion manual in the hospital

: We report a B Rh negative patient undergoing total pelvic exenteration, who received both ABO and Rh incompatible packed red blood cells in an emergency situation. After this experience, we revised the manual of emergency blood transfusion. We defined level of severity to share information with surgeon, nurses, anesthesiologists and the member of the blood center. We changed anesthesia information management system for showing blood type including Duffy blood group system and checking out whether we can transfuse Rh positive blood to Rh negative patient in an emergency situation at the timeout of surgery.