HospitalInspections.org

Based on policy and procedure review, review educational information for nurse training, open and closed medical record reviews and staff interviews the nursing staff failed to administer blood per the hospital policy by failing to administer a blood transfusion as ordered by the physician and failing to stop a blood transfusion for potential signs and symptoms of a transfusion reaction in 2 of 4 patients receiving blood transfusions reviewed ( #9 and # 4).

The findings include:

Review of hospital policy "IV - Administration of Blood and Blood Products" revised June 2009 revealed "...A Physician's order is required for the administration of blood and blood products...If any changes in patient's condition occur after blood products are started, stop the transfusion and follow reaction protocol (See Complications)...Notify the physician immediately for any signs/symptoms of reaction...Complications Observe the patient for any of the following symptoms...Fever-most common sign ( 1 - 2 degree F increase from baseline)...Decreased BP...For signs/symptoms of any type of reaction: Assess the patient and implement the following activities if any of the above symptoms are exhibited. Stop the infusion."

Review of "IV Review Class May 2009 [Blood and Blood Product Administration]" revealed "Signs and Symptoms vary a bit between reactions (see chart at back of handout)...Notify Blood Bank within 15 minutes of stat of symptoms...Fever, chills occur first Even 1 degree F increase in temp could indicate reaction...Decreased BP (Blood Pressure)...Blood Reactions...--Fever spike (even 1 degree F increase indicates possible reaction)...--Decreased BP."


1. Open medical record review of Patient # 9 revealed the 90 year old was admitted on 2-19-2010 for a right knee arthroscopy. Record review revealed physician's orders on 2-20-2010 for the patient to be transfused 2 units of PRBC's each over 2 - 4 hours. Record review revealed the Unit 12LE38115 was started at 2230. Record review revealed vital signs at 2215 (Baseline - pre) were temperature 99.3, Pulse 88, respiration 20, and blood pressure 119/64. Review revealed the patients vitals signs 15 minutes after the transfusion was started at 2245 were temperature 100.9 ( 1.6 degree increase), pulse 80, respirations 20 and blood pressure 94/46. Record review revealed the transfusion continued and at 2315 the patient's temperature was 100.5. Record revealed no documentation of the physician being notified of the 1.6 degree increase in temperature or documentation of the staff stopping the transfusion due to a increase in temperature of 1.6 degrees (1-2 degree increase in temperature sign of potential transfusion reaction per the facility policy). Interview with nursing staff on 2-24-2010 at 1415 revealed the staff should have stopped the transfusion. The interview revealed the increase in temperature was a sign of a potential transfusion reaction. The interview revealed there was no documentation of why the transfusion was not stopped.

2. Medical record review of Patient # 4 revealed a 44 year old patient presenting to the emergency Department on 1-20-2010 for a complaint of vaginal bleeding and anemia. Record review revealed the physician ordered for the patient to be given 2 units of Packed Red Blood Cells (PRBC) on 1-20-2010. Record review revealed the first transfusion was started at 1340 and discontinued at 1350 due to the patient having a complaint of chest pain. Record review revealed no documentation of the patient receiving the second unit of blood as ordered. Record review did not reveal any documentation of an order to not give the patient the second unit of blood. Record review revealed no documentation of why the patient did not receive the second transfusion as ordered. Interview with nursing staff on 2-24-2010 at 1500 revealed there was no documentation of a physician's order to discontinue the administration of the second unit of PRBCs. The interview revealed there was no documentation available of why the patient did not receive the transfusion as ordered. The interview revealed the nursing staff should have obtained a physician's order to not give the second transfusion.