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Based on record review and staff interview, it was determined that the governing body failed to ensure that the same day surgery charge nurse consistently and properly managed critical information, related to a blood bank error, for one (1) patient with a significant Rh antigen blood group, in order to avert or reduce the opportunity for possible medical errors. Patient # N 1.

The findings included:

Hospital Policy # 02-31-31, entitled ' Management of Verbally Reported Critical Values, effective December 12, 2008, (in effect at time of incident), included and directed the following guidelines and stipulations under the section related to Procedures for ' Departments Receiving Critical Value Results: " 1)The clinician receiving a critical value result verbally (either in person or by telephone) will write down the test result; 2) The clinician should then " read back " the critical result and receive confirmation from the individual reporting the critical result. During the " read back " step, the clinician verifies numeric values, spelling, the first and last name of the person giving the results, the patient ' s name, medical record number, and any other pertinent information associated with the critical value result; 3) The nurse will notify the care provider of the reported value immediately or no more than 60 minutes after receipt of the critical value; 4) The nurse will document the value, the time it was called, the first and last name of the individual reporting, the time and name of the receiving clinician, name of MD notified as well as indicate if MD orders were given, on the Critical Value Test Results yellow sticker; and 5) The Critical Value Test Results Yellow sticker will then be placed in the Progress Notes section of the patient ' s medical record. "

Patient # N1 was admitted to the hospital on January 4, 2011 for same day surgery, for a Dilation and Curettage with Suction. The patient was diagnosed with a missed abortion one (1) day prior to admission, after serial sonograms, performed one (1) week apart, demonstrated a collapsing gestational sac and a six (6) week fetus without cardiac activity.

Evidence was present in the medical record that Patient # N1 had pre-operative (pre-op) lab work performed at the hospital on the same morning of his/her scheduled ' Same Day Surgery ' . Documentation in the ' Review of Systems-History ' included the following entry under the ' Pre-Op Checklist ' notation: " Labs done, results pending, RH. "

The blood type and Rh factor results would determine whether or not the patient would require a therapeutic injection of the immune globulin, RhoGam.

Subsequent documentation entered on the physician ' s ' Short Stay Record (H&P), dated and signed January 4, 2011 at 11:00 A.M. included the results of the patient ' s blood type, received from the hospital lab, recorded as " O positive " .

It was determined through interview with the charge nurse that a blood bank employee had inadvertently recorded and entered the wrong patient blood type and Rh factor into the hospital ' s computer system. The patient was later determined to be blood type ' A negative " and not ' O positive ' as initially reported by the blood bank tech.

The computer entry was recognized immediately by the technician (tech) and verbal communication by telephone was made directly with the Same Day Surgery unit to alert the healthcare team of the error.

During a face-to-face interview conducted with the charge nurse on March 10, 2011 at approximately 11:40 A.M., he/she acknowledged receiving the verbal communication and alert from the lab tech concerning the blood bank error for Patient # N1.

Even though the patient had already been transported to the O.R., the notification had been received by the charge nurse and acknowledged prior to the completion of the patient ' s surgical procedure and prior to his/her discharge from the hospital.

However, there was no documented evidence that the charge nurse properly managed the critical information concerning the patient ' s inaccurately reported Rh factor, as a critical value result and implemented the respective hospital policy.

A review of the medical record lacked documented evidence that the charge nurse alerted the O.R. to ensure that the critical lab error, referencing the patient ' s blood type and Rh factor, had been immediately communicated to the attending physician or another member of the O.R. team. The charge nurse initially claimed to have attempted to call the O.R., however this allegation could not be verified or corroborated.

Additionally, interview with the charge nurse on March 10, 2011 at approximately 11:45 A.M. revealed that not only was the critical information not managed as a critical value and given to the attending physician and the O.R. team; but he/she also failed to ensure proper hand-off of the communication to the oncoming nursing shift.

Consequently, neither the attending physician nor other members of the O.R. team, nor the nurses caring for the patient post surgery were ever alerted or informed of the lab error and correction. Patient # N 1 was subsequently discharged from the hospital without receiving therapeutic treatment for his/her Rh negative blood type.

A face-to-face interview was conducted with the nurse manager, on March 10, 2011at approximately 12:00 P.M. He/she was present during the interview with the charge nurse and review of the aforementioned findings. When queried as to whether the error notification should have been considered and/or managed as a critical value report, the nurse manager stated that " now it is " ; but also included that " it should have been handled as a critical value " .

The record was reviewed March 10, 2011.

Based on record review and staff interview, it was determined that the charge nurse failed to act in accordance with accepted standards of nursing practice, as evidenced by the following: failure to ensure that a critical blood bank error was immediately communicated to the attending physician for one (1) patient undergoing a same day surgical procedure; and, failure to ensure proper hand-off communication of critical lab error results was given to the oncoming nursing shift for immediate follow-up and intervention. Patient # N1.

The findings included:

In accordance with Title 17 District of Columbia Municipal Regulations (DCMR) for Registered Nurses, Chapter 54, Section 5414, titled ' Scope of Practice ' , the following directive was stipulated under subsection 5414.1 (i): " The practice of registered nursing means the performance of acts requiring substantial specialized knowledge, judgment, and skill based upon the principles of the biological, physical, behavioral, and social sciences in the following: (i) Communicating and collaborating with other health care team members and professionals in the development of the plan of care, management of the client ' s health care, and the implementation of the total health care regimen. "

Patient # N1 was admitted to the hospital on January 4, 2011 for same day surgery, for a Dilation and Curettage with Suction. The patient was diagnosed with a missed abortion one (1) day prior to admission, after serial sonograms, performed one (1) week apart, demonstrated a collapsing gestational sac and a six (6) week fetus without cardiac activity.

Evidence was present in the medical record that Patient # N1 had pre-operative (pre-op) lab work performed at the hospital on the same morning of his/her scheduled ' Same Day Surgery ' . Documentation in the ' Review of Systems-History ' included the following entry under the ' Pre-Op Checklist ' notation: " Labs done, results pending, RH. " The blood type and Rh factor results would determine whether or not the patient would require a therapeutic injection of the immune globulin, RhoGam.

Subsequent documentation entered on the physician ' s ' Short Stay Record (H&P), dated and signed January 4, 2011 at 11:00 A.M. included the results of the patient ' s blood type, received from the hospital lab, recorded as " O positive " .

It was determined through interview with the charge nurse that a blood bank technician had inadvertently recorded and entered the wrong patient blood type and Rh factor into the hospital ' s computer system. The patient was later determined to be blood type ' A negative " and not ' O positive ' as initially reported by the blood bank tech.

The computer entry error was recognized immediately by the technician (tech) and verbal communication with the same day surgical unit was made at that time to alert the healthcare team of the error.

During a face-to-face interview conducted with the charge nurse on March 10, 2011 at approximately 11:40 A.M., he/she acknowledged receiving the verbal communication and alert from the lab concerning the blood bank error for Patient # N1. Although the patient had been transported to the O.R., the notification and receipt by the charge nurse had been received and acknowledged prior to the completion of the patient ' s surgical procedure and prior to his/her discharge from the hospital.

However, continued face-to-face inquiry determined that the charge nurse failed to alert the O.R. to ensure that the critical lab error, referencing a correction in the patient ' s previously reported blood type and Rh factor, had been immediately communicated to the surgical attending or another member of the O.R. team. The corrected results now determined the patient ' s need for specific therapeutic treatment previously discussed by his/her physician.

The charge nurse stated he/she attempted to call the O.R., however after thorough inquiry, this statement could not be verified or corroborated.

Further interview and inquiry concluded the following additional deficient practice findings: the charge nurse acknowledged that there were no further attempts made to contact either the physician or the O.R. team once the patient was transported from the pre-op area; he/she failed to actively pursue all measures to ensure that the physician and/or other members of the health care team were informed and alerted concerning the blood bank error; failed to ensure proper hand-off of communication was given to the oncoming nursing shift, concerning the blood bank error, so that immediate follow-up interventions would be implemented; and failed to promptly provide and document a nursing progress note detailing notification and receipt of the lab error and its significance related to the need for further patient care and management.

Consequently, neither the attending physician nor other members of the O.R. team, nor the nurses caring for the patient post surgery were ever alerted or informed of the lab error and correction. The patient was subsequently discharged from the hospital without receiving proper therapeutic treatment for his/her Rh negative blood type.

The record was reviewed March 10, 2011.

Based on record review and staff interview, it was determined that the charge nurse failed to promptly provide and document a nursing progress note detailing notification and receipt of a critical lab error and its significance, related to the subsequent management of one (1) patient with an inaccurately reported Rh antigen blood group. Patient # N 1.

The findings included:

Hospital Policy # 03-31-32, entitled ' Charting/Documentation in the Medical Record ' , effective date September 2, 2009, included the following statement related to the policy statement; and stipulated and included the following directives under the subsection referencing acceptable charting/documentation practices, respectively: " The medical record is a multidisciplinary medical record that communicates critical information to other healthcare providers about the patient, the medical services provided to the patient and the outcomes and response from those medical services ...Item # 10) Documentation in the medical record may be captured electronically or on paper " . Under the section titled ' Daily or Shift Documentation ' the following guidelines were included under ' Significant Events ' and ' Critical Test Results ' : " Any unusual or significant event should be documented in this folder; and, Document any critical test results that are received from lab or imaging services. Documentation should include: Lab or imaging result; Notification of MD or other pertinent caregiver; Intervention; Patient Response. "

Patient # N1 was admitted to the hospital on January 4, 2011 for same day surgery, for a Dilation and Curettage with Suction. The patient was diagnosed with a missed abortion one (1) day prior to admission, after serial sonograms, performed one (1) week apart, demonstrated a collapsing gestational sac and a six (6) week fetus without cardiac activity.

Evidence was present in the medical record that Patient # N1 had pre-operative (pre-op) lab work performed at the hospital on the same morning of his/her scheduled ' Same Day Surgery ' . Documentation in the ' Review of Systems-History ' included the following entry under the ' Pre-Op Checklist ' notation: " Labs done, results pending, RH. "

The blood type and Rh factor results would determine whether or not the patient would require a therapeutic injection of the immune globulin, RhoGam.

Subsequent documentation entered on the physician ' s ' Short Stay Record (H&P), dated and signed January 4, 2011 at 11:00 A.M. included the results of the patient ' s blood type, received from the hospital lab, recorded as " O positive " .

It was determined through interview with the charge nurse that a blood bank technician had inadvertently recorded and entered the wrong patient blood type and Rh factor into the hospital ' s computer system. The patient was later determined to be blood type ' A negative " and not ' O positive ' as initially reported by the blood bank tech.

The computer entry was recognized immediately by the technician (tech) and verbal communication by telephone was made directly with the Same Day Surgery unit to alert the healthcare team of the error.

During a face-to-face interview conducted with the charge nurse on March 10, 2011 at approximately 11:40 A.M., he/she acknowledged receiving the verbal communication and alert from the lab tech, concerning the blood bank error for Patient # N1.

However, continued face-to-face inquiry determined that the charge nurse failed to alert the O.R. to ensure that the critical lab error, referencing a correction in the patient ' s previously reported blood type and Rh factor had been immediately communicated to the surgical attending or another member of the O.R. team. The corrected results now determined the patient ' s need for specific therapeutic treatment previously discussed by his/her physician.

The charge nurse stated he/she attempted to call the O.R., however after thorough inquiry, this statement could not be verified or corroborated.

Record review revealed and corroborated that the charge nurse also failed to document a progress note entry detailing notification and receipt of the critical lab error and, its significance related to the subsequent care and management needs of the patient.

Therefore, critical information regarding the inaccurate recording of the patient ' s blood type and Rh factor was not made available to the physician or the O.R. team in order to provide the patient with the appropriate therapeutic care and treatment.

A face-to-face interview was conducted with the nurse manager, on March 10, 2011 at approximately 12:00 P.M. He/she was present during the interview with the charge nurse and review of the aforementioned findings. He/she acknowledged that the charge nurse failed to document a progress note detailing the events related to notification and receipt of the results of the patient ' s critical lab changes. The record was reviewed March 10, 2011.