Introduction: Pediatric patients should not be exposed to blood components and products unnecessarily. Transfusion-related risks are always present, both those we know and those that remain to be discovered. It is essential to follow good transfusion practice (GTP) procedures; although they can sometimes be quite prescriptive, evidence shows that when we ignore guidelines, errors can occur. Case Report: We report the case of a 7-month-old infant who underwent surgery for megacolon and received emergency transfusions. The death of the infant post-surgery prompted a hemovigilance investigation to determine the imputability of the transfusion. Conclusion: The investigation revealed deficiencies in the patientandrsquo;s transfusion management, some of which were critical. This indicates that nurses have a considerable knowledge deficit in blood transfusion; however, the infantandrsquo;s death was not attributable to transfusion and was due to post-surgical complications.
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