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Based on a review of hospital policies and procedures, medical record reviews, review of an RCA (root cause analysis) Action Plan and staff interviews, the hospital's governing body failed to provide effective oversight of the organized nursing service and have systems in place to protect a patient's right to care in a safe setting as related to a patient receiving the wrong blood type during a transfusion.

The findings include:

1. The hospital failed to protect and promote a patient's right to receive care in a safe setting. Nursing staff failed to follow the blood administration procedure of visually verifying a blood product transfusion form matched a patient's blood bracelet.

~ cross refer to §482.13(c)(2) Patient's Rights Condition: Tag A-0144

2. The hospital's nursing service failed to provide effective oversight of nursing staff to ensure blood was administered in accordance with hospital policy. Nursing staff failed to visually verify that a blood product transfusion form matched a patient's blood bracelet; which resulted in the wrong blood type being given to a patient.

~ cross refer to §482.23(c)(4) Nursing Services Condition: Tag A-0410

Based on a review of hospital policies and procedures, medical record reviews, an RCA (root cause analysis) Action Plan review and staff interviews, the hospital failed to promote and protect a patient's rights by failing to ensure a patient received the correct blood type during a required transfusion in 1 of 6 blood transfusion records reviewed (Patient #2).

The findings include:

1. The nursing staff initiated the transfusion of A+ blood to a patient with an A- blood type after failing to visually verify that the blood product transfusion form matched the patient's blood bracelet.

~ cross refer to §482.13(c)(2) Patient Rights Standard: Tag A-0144

Based on review of policies and procedures, medical records, facility documents, and staff interviews, facility staff failed to provide care in a safe setting related to blood transfusions for 1 of 6 sampled patients reciving a transfusion (Patient #2), by failing to visually verify that the correct blood product was provided to the correct patient.

The findings include:

Review of the facility's "Blood Administration, Whole blood and Packed Red Blood Cells" policy revised 06/2019 revealed, "Purpose: 1. To provide guidelines for the registered nurse (RN)...for the administration of whole blood and packed red blood cells. Responsibility/Scope of Practice:...Procedure:...Verification of Blood Product: 6. Two licensed people, one of whom is an RN, will verify the physician's order for the blood transfusion. 7. Two licensed people, one of whom is the RN transfusionist (sic), will at the patient's bedside verify: Blood Product ordered, EPIC order <--> Product Bag Label <--> Blood Product Transfusion Form. Blood Type, EPIC <--> Product Bag Label <--> Blood Product Transfusion Form. Name, Date of Birth, Medical Record Number, Patient's Bracelet <-->Blood Product Transfusion Form <--> EPIC. Blood Product Unit Number, Blood Product Bag Label <--> Blood Product Transfusion Form <--> EPIC. Blood Bracelet Number, Blood Bracelet <--> Blood Product Transfusion Form. a. Verify the blood product received with the physician's order, the blood product bag label, and the blood product Transfusion Form to ensure the correct blood product is being transfused...b. If the type of blood product does not match the order, label or Blood Product Transfusion Form-do NOT proceed with the transfusion, notify the Transfusion Center...REMEMBER: Identifying the patient blood product correctly is the most important step in preventing life-threatening transfusion reactions...8. Scan the labels on the blood product bag then scan the patient...9. Scanning the blood product does not confirm blood type compatibility or verify patient identification...11. After the patient's identification and blood type have been verified with the patient, spike the blood and connect the blood product to the patient and begin the transfusion..."

Closed medical record review for Patient #2 on 07/14/2020 revealed he was a 48-year-old male who was transported to the emergency department (ED) on 06/13/2020 at 0842 after a syncopal episode while on his way to the bathroom in the early morning. Review of the History of Present Illness (HPI) dated 06/13/2020 at 1009 by the ED physician (MD #1) revealed Patient #2's history included alcohol abuse and a clotting disorder for which he had been prescribed warfarin. Review of the HPI revealed Patient #2 had stopped warfarin two weeks earlier "because he is concerned his INR will get too high," and Patient #2's hemoglobin was 6.8 grams/deciliter (normal = 13.5-17.5 g/dL), hematocrit was 23.3% (normal = 40.7-50.3%) and "...the Patient will be transfused ...Plan at this time is admission to the hospital for further treatment of his acute anemia..." Review of the ED Patient Care Timeline revealed an order to "Transfuse Packed Red Blood Cells (PRBC)" was placed by MD #1 on 06/13/2020 at 1016 and at 1254, unit number "W0368 20 226964" was started at 125 milliliters (ml) per hour by registered nurse (RN) #3. Review of the "Pretransfusion Check" revealed "Yes" answers to the questions, "Name and ID numbers match? Blood groups are compatible? Patient able to confirm documented blood type? Blood bank armband matches identifier on blood bank tag? Blood bag matches blood bag tag? Previous transfusion? and a "No" answer to the question, History of previous reaction? Further review revealed RN #3 indicated the transfusion had been stopped at 1256, and at the same time, RN #4 charted 5 of approximately 300 ml of PRBC's had been given. Review of "ED Notes" by RN #5 dated 06/13/2020 at 1305 revealed "Noted patient received wrong blood. Patient noted disconnected by two other nurses ...Charge nurse notified and MD Notified..." Review of an "ED Provider Notes Addendum" by MD #1 dated 06/13/2020 at 1416 revealed "I was informed that the patient received a small amount less than 5mL's of a positive (sic) blood although the patient is a negative (sic). This has been escalated to nursing leadership..."

Review of the Laboratory Services "Event Investigation and Root Cause Analysis" (undated) revealed an A-positive unit of blood, W0368 20 226964, was sent from laboratory services via the facility tube system to the ED for an (unidentified) patient on 06/13/2020 at 1244. Review revealed a unit of A-negative blood, W0368 20 000736, was assigned to Patient #2 and sent to the ED via the tube system on 06/13/2020 at 1253. Review revealed both assigned blood units were labeled with the correct patient information. Review revealed the A-positive unit of blood, W0368 20 226964, was scanned and entered into Patient #2's record as started on 06/13/2020 at 1254. Review revealed two nursing staff members had not followed "established Blood Administration policies regarding clerical checks vital to prevention of transfusion errors." It was noted that unlike medications, scanning did not link a specific patient to the correct product.

Review of the facility "Root Cause Analysis" (undated) revealed nursing staff had not verified patient information as specified in the transfusion policy's workflow. Review revealed Patient #2's primary nurse had been away from the ED transporting another patient when she had been informed the unit of blood had been tubed to the ED and had called a covering staff member to request her assistance in starting the transfusion. Review revealed the covering nurse and a second nurse (both unnamed) "did not verify the patient using arm bracelet and did not compare the blood bracelet information with the blood." Review revealed a similar "event could happen in any department of the hospital ...where blood products are administered." Review revealed, scanning the blood product may have provided "a false sense of security" because scanning medications linked a patient's data to medications, they were to receive but scanning blood products did not provide similar linking. It was noted that the facility's electronic record system had a scanning program which would link patient information and blood product data, but it would not be available at the facility for 2-3 years.

Review of an "Action Plan Progress" timeline (undated but completed entries dated 06/13/2020 - 07/14/2020) revealed one of the two (unnamed) nurses involved in the blood administration error received "1:1 education" on 06/30/2020 and the second nurse received "1:1 education" on 07/02/2020. Review revealed on 07/14/2020 there was an "Education board placed in Emergency Department involving blood administration process for RNs to sign off on,," and an email had been sent to all ED RN's about the blood administration process.

Review of personnel files revealed an "Employee Communication Report" and "Written Warning" signed by RN #3 and her supervisor RN #7 on 0707/2020 with a chronological summary pertaining to the events of 06/13/2020. The review revealed RN #3 had picked up a unit of blood at the tube station but had not looked at the name or blood type on the attached slip. Review revealed, during verification process neither RN #3 nor RN #5 viewed the blood bank bracelet on Patient #2's wrist, and although Patient #2's identification bracelet had been scanned, neither RN #3 nor RN #5 verified that the name on the blood slip matched the name in the electronic record. Further review revealed there was not a written warning available which documented RN #5's participation in verification of the blood product for Patient #2.

Telephone interview on 07/15/2020 at 1100 with RN #4 revealed she had been at the facility for two years and worked in the facility's ED. RN #4 revealed she had been Patient #2's primary nurse, and was transporting another patient to an inpatient unit when she was notified by transfusion services that the unit of blood was being sent to the ED via the tube system. Interview revealed RN #4 called RN #3 who was covering for her, and asked RN #3 to see if the blood had arrived. When RN #4 returned to the unit she saw that RN #3 and RN #5 were starting the transfusion and she went get a thermometer for the next set of vital signs. As RN #4 returned to Patient #2's room with the thermometer another RN approached with a unit of blood and said, "I think this is yours." RN #4 stated I went into my patient's room and looked at the patient name on the hanging unit and saw it did not have my patient's name on it and I pressed stop." Interview revealed as RN #4 disconnected the tubing from the patient, RN #5 informed the charge nurse the incorrect unit of blood had been started and when RN #5 returned to the room, she informed RN #4 that hematology was consulted. Interview revealed RN #4 checked the pump volume infused, noted it was 15.8 ml, which indicated the first 10 ml infused would have been normal saline since it was used to prime the intravenous tubing. RN #4 estimated that Patient #2 had received approximately 5.8 ml of incorrect blood. RN #4 revealed MD #1 and MD #6 had seen and talked with Patient #2 about the transfusion mismatch, and believed he was stable when he transferred to the inpatient service.

Telephone interview on 07/15/2020 at 1140 with RN #5 revealed she had been a nurse for over eight years and had worked in the facility's ED for three years. RN #5 revealed RN #3 was covering RN #4's assignment while RN #4 transported a patient to an inpatient unit, "and asked me to help her. I said OK and went into the room. The blood was hanging and spiked." Interview revealed as RN #3 programmed the pump, RN #5 introduced herself, asked Patient #2 his blood type, if he had received blood before, and if he'd had any previous reactions. RN #5 charted Patient #2 did not recall his blood type but called his primary care physician's office for the information. Interview revealed RN #5 had verified information on the transport slip against the information RN #3 had read to her, and the information on the computer screen then left the room and returned to her assignment. Interview revealed "two or three minutes later (RN #3) came around the corner and said there was something wrong with the blood." RN #5 revealed she returned to Patient #2's room and "saw on the C.O.W. (computer on wheels) there was another unit of blood with the patient's name on it." RN #5 revealed "Now I know what I failed to do...I did not follow the policy and look at the slip"

Telephone interview on 07/15/2020 at 1210 with RN #3 revealed she had been a nurse in the facility's ED for two and a half years, and a nurse for five years. Interview revealed Patient #2's primary nurse was transporting a patient to an inpatient unit and RN #3 was providing oversight to the remainder of RN #4's patients while she was off the unit. Interview revealed RN #4 had called and asked RN #3 "to get the blood. I walked directly to the tube station, got the blood and hung it on the pole." Interview revealed RN #3 asked RN #5 to help verify the blood and she had scanned the patient's hospital identification bracelet's bar code while RN #5 began verifying information from the lab bracelet which does not have a bar code identifier, with Patient #2. Interview revealed two nurses "would be typically verifying the (lab) bracelet with the blood order (and) checking paperwork but that didn't happen." Interview with RN #3 revealed a few minutes after starting the transfusion "there was another unit and we thought it was a second unit until we looked and saw it was the patient's blood and the hanging blood was someone else's." RN #3 stated we should have looked at the paperwork that came with the blood and paid more attention.

Interview on 07/15/2020 at 1545 with RN #9 revealed she had been a nurse in the facility's ED for four and a half years and was aware of the "blood incident." Interview revealed some staff were unaware that scanning the unit of blood did not create a "hard stop" if it was "not the correct unit."

Interview on 07/15/2020 at 0900 and at 1600 with the ED Manager, revealed he had managed the ED for 18 years. The ED Manager revealed scanning a blood product into a record simply prevents a transcription error but does not verify the blood product is the correct one for the patient. Interview revealed patient and blood product information must be visually verified by staff, and RN #3 and RN #5 had failed to perform parts the visual verification for Patient #2. Interview revealed that when the nurses involved in the mismatched transfusion were questioned, one had indicated she used "EPIC for verification and the other said you couldn't use EPIC for verification." Interview revealed the same preceptor trained both staff on the transfusion protocol.

Interview on 07/16/2020 at 1340 with the CNO (Chief Nursing Officer) revealed senior leadership was aware that it remained possible for two staff to circumvent visual verification of required information prior to initiating a blood transfusion, but new adjustments to the process were being initiated.

Based on a review of hospital policies and procedures, an RCA Action Plan review, medical record reviews and staff interviews, the hospital's organized nursing service failed to provide effective oversight of nursing staff and have systems in place to ensure safe delivery of care to patients requiring a blood transfusion.
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The findings include:

1. Nursing staff failed to follow blood administration procedures and visually verify the blood product transfusion form matched a patient's blood bracelet in 1 of 6 sampled blood transfusion records (Patient #2).

~ cross refer to §482.23(c)(4) Nursing Services Standard: Tag A-0410

Based on review of policies and procedures, medical records, facility documents, and staff interviews, facility staff failed to ensure the correct blood product was administered to the correct patient for 1of 6 sampled patients who received a bedside blood transfusion (Patient #2).

The findings include:

Review of the facility's "Blood Administration, Whole blood and Packed Red Blood Cells" policy revised 06/2019 revealed, "Purpose: 1. To provide guidelines for the registered nurse (RN)...for the administration of whole blood and packed red blood cells. Responsibility/Scope of Practice:...Procedure:...Verification of Blood Product: 6. Two licensed people, one of whom is an RN, will verify the physician's order for the blood transfusion. 7. Two licensed people, one of whom is the RN transfusionist (sic), will at the patient's bedside verify: Blood Product ordered, EPIC order<-->Product Bag Label<-->Blood Product Transfusion Form. Blood Type, EPIC<-->Product Bag Label ... Blood Product Transfusion Form. Name, Date of Birth, Medical Record Number, Patient's Bracelet<-->Blood Product Transfusion Form<-->EPIC. Blood Product Unit Number, Blood Product Bag Label<-->Blood Product Transfusion Form<--> EPIC<-->Blood Bracelet Number, Blood Bracelet<-->Blood Product Transfusion Form. a. Verify the blood product received with the physician's order, the blood product bag label, and the blood product Transfusion Form to ensure the correct blood product is being transfused...b. If the type of blood product does not match the order, label or Blood Product Transfusion Form-do NOT proceed with the transfusion, notify the Transfusion Center...REMEMBER: Identifying the patient blood product correctly is the most important step in preventing life-threatening transfusion reactions. d. Do NOT proceed if the information does not match...h. Verify the blood product unit number on the blood bag matches the Blood Product Transfusion Form. i. Verify the number on the patient's blood bracelet matches the Blood Product Transfusion Form...8. Scan the labels on the blood product bag then scan the patient...9. Scanning the blood product does not confirm blood type compatibility or verify patient identification...11. After the patient's identification and blood type have been verified with the patient, spike the blood and connect the blood product to the patient and begin the transfusion..."

Closed medical record review for Patient #2 on 07/14/2020 revealed he was a 48-year-old male who was transported to the emergency department (ED) on 06/13/2020 at 0842 after a syncopal episode while on his way to the bathroom in the early morning. Review of the History of Present Illness (HPI) dated 06/13/2020 at 1009 by the ED physician (MD #1) revealed Patient #2's history included alcohol abuse and a clotting disorder for which he had been prescribed warfarin. Review of the HPI revealed Patient #2 had stopped warfarin two weeks earlier "because he is concerned his INR will get too high," and Patient #2's hemoglobin was 6.8 grams/deciliter (normal = 13.5-17.5 g/dL) (red blood cell protein which carries oxygen to the cells), hematocrit was 23.3% (ratio of red blood cells in a volume of blood) (normal = 40.7-50.3%). Review revealed " ...the Patient will be transfused ...Plan at this time is admission to the hospital for further treatment of his acute anemia ..." Review of the ED Patient Care Timeline revealed an order to "Transfuse Packed Red Blood Cells (PRBC)" was placed by MD #1 on 06/13/2020 at 1016 and at 1254, unit number "W0368 20 226964" was started at 125 milliliters (ml) per hour by registered nurse (RN) #3. Review of the "Pretransfusion Check" revealed "Yes" answers to the questions, "Name and ID numbers match? Blood groups are compatible? Patient able to confirm documented blood type? Blood bank armband matches identifier on blood bank tag? Blood bag matches blood bag tag? Previous transfusion? and a "No" answer to the question, History of previous reaction? Further review revealed RN #3 indicated the transfusion had been stopped at 1256, and at the same time, RN #4 charted 5 of approximately 300 ml of PRBC's had been given. Review of "ED Notes" by RN #5 dated 06/13/2020 at 1305 revealed "Noted patient received wrong blood. Patient noted disconnected by two other nurses...Charge nurse notified and MD Notified..." Review of an "ED Provider Notes Addendum" by MD #1 dated 06/13/2020 at 1416 revealed "I was informed that the patient received a small amount less than 5 mL's of a positive (sic) blood although the patient is a negative (sic). This has been escalated to nursing leadership...He is not hypotensive. He has no signs of shock. I did contact hematology and request a consultation...I did discuss this with the patient and his family member..."

Review of the Laboratory Services "Event Investigation and Root Cause Analysis" (undated) revealed an A-positive unit of blood, W0368 20 226964, was sent from laboratory services via the facility tube system to the ED for an (unidentified) patient on 06/13/2020 at 1244. Review revealed a unit of A-negative blood, W0368 20 000736, was assigned to Patient #2 and sent to the ED via the tube system on 06/13/2020 at 1253. Review revealed both assigned blood units were labeled with the correct patient information. Review revealed the A-positive unit of blood, W0368 20 226964, was scanned and entered into Patient #2's record as started on 06/13/2020 at 1254. Review revealed two nursing staff members had not followed "established Blood Administration policies regarding clerical checks vital to prevention of transfusion errors." It was noted that unlike medications, scanning did not link a specific patient to the correct product.

Review of the facility "Root Cause Analysis" (undated) revealed nursing staff had not verified patient information as specified in the transfusion policy's workflow. Review revealed Patient #2's primary nurse had been away from the ED transporting another patient when she had been informed the unit of blood had been tubed to the ED and had called a covering staff member to request her assistance in starting the transfusion. Review revealed the covering nurse and a second nurse (both unnamed) "did not verify the patient using arm bracelet and did not compare the blood bracelet information with the blood." Review revealed a similar "event could happen in any department of the hospital ...where blood products are administered." Review revealed, scanning the blood product may have provided "a false sense of security" because scanning medications linked a patient's data to medications, they were to receive but scanning blood products did not provide similar linking. It was noted that the facility's electronic medical record system had a scanning program which would link patient information and blood product data, but it would not be available at the facility for 2-3 years.

Review of an "Action Plan Progress" timeline (undated but completed entries dated 06/13/2020 - 07/14/2020) revealed one of the two (unnamed) nurses involved in the blood administration error received "1:1 education" on 06/30/2020 and the second nurse received "1:1 education" on 07/02/2020. Review revealed on 07/14/2020 there was an "Education board placed in Emergency Department involving blood administration process for RNs to sign off on," and an email had been sent to all ED RN's about the blood administration process. Review revealed a "Follow-up meeting with key stakeholders to discuss findings and determine action plan" was scheduled for 07/16/2020. Review on 07/15/2020 at 0930 revealed no indication that facility wide training updates for staff who participated in blood product administration had been scheduled, and a "Meeting with EPIC leadership to discuss Beaker Module implementation (the electronic medical record module capable of linking a patient with laboratory results via scanning) in the future" was "TBD."

Review of an "Action Plan Progress" timeline (undated but completed entries dated 06/13/2020 - 07/14/2020) revealed one of the two (unnamed) nurses involved in the blood administration error received "1:1 education" on 06/30/2020 and the second nurse received "1:1 education" on 07/02/2020. Review revealed on 07/14/2020 there was an "Education board placed in Emergency Department involving blood administration process for RNs to sign off on," and an email had been sent to all ED RN's about the blood administration process.

Review of personnel files revealed an "Employee Communication Report" and "Written Warning" signed by RN #3 and her supervisor RN #7 on 0707/2020 with a chronological summary pertaining to the events of 06/13/2020. The review revealed RN #3 had picked up a unit of blood at the tube station but had not looked at the name or blood type on the attached slip. Review revealed, during verification process neither RN #3 nor RN #5 viewed the blood bank bracelet on Patient #2's wrist, and although Patient #2's identification bracelet had been scanned, neither RN #3 nor RN #5 verified that the name on the blood slip matched the name in the electronic record. Further review revealed there was not written warning documentation of RN #5's participation in verification of the blood product for Patient #2.

Telephone interview on 07/15/2020 at 1100 with RN #4 revealed she had been at the facility for two years and worked in the facility's ED. RN #4 revealed she had been Patient #2's primary nurse, and was transporting another patient to an inpatient unit when she was notified by transfusion services that the unit of blood was being sent to the ED via the tube system. Interview revealed RN #4 called RN #3 who was covering for her, and asked RN #3 to see if the blood had arrived. When RN #4 returned to the unit she saw that RN #3 and RN #5 were starting the transfusion and she went to get a thermometer for the next set of vital signs. As RN #4 returned to Patient #2's room with the thermometer another RN approached with a unit of blood and said, "I think this is yours." RN #4 stated I went into my patient's room and looked at the patient name on the hanging unit and saw it did not have my patient's name on it and I pressed stop." Interview revealed as RN #4 disconnected the tubing from the patient, RN #5 informed the charge nurse the incorrect unit of blood had been started and when RN #5 returned to the room, she informed RN #4 that hematology was consulted. Interview revealed RN #4 checked the pump volume infused, noted it was 15.8 ml, which indicated the first 10 ml infused would have been normal saline since it was used to prime the intravenous tubing. RN #4 estimated that Patient #2 had received approximately 5.8 ml of incorrect blood. RN #4 revealed MD #1 and MD #6 had seen and talked with Patient #2 about the transfusion mismatch, and believed he was stable when he transferred to the inpatient service.

Telephone interview on 07/15/2020 at 1140 with RN #5 revealed she had been a nurse for over eight years and had worked in the facility's ED for three years. RN #5 revealed RN #3 was covering RN #4's assignment while RN #4 transported a patient to an inpatient unit, "and asked me to help her. I said OK and went into the room. The blood was hanging and spiked." Interview revealed as RN #3 programmed the pump, RN #5 introduced herself, asked his blood type, if he had received blood before, and if he'd had any previous reactions. RN #5 charted Patient #2 did not recall his blood type but called his primary care physician's office for the information. Interview revealed RN #5 had verified information on the transport slip against the information RN #3 had read to her, and the information on the computer screen then left the room and returned to her assignment. Interview revealed "two or three minutes later (RN #3) came around the corner and said there was something wrong with the blood." RN #5 revealed she returned to Patient #2's room and "saw on the C.O.W. (computer on wheels) there was another unit of blood with the patient's name on it." RN #5 revealed "Now I know what I failed to do ...I did not follow the policy and look at the slip"

Telephone interview on 07/15/2020 at 1210 with RN #3 revealed she had been a nurse in the facility's ED for two and a half years, and a nurse for five years. Interview revealed Patient #2's primary nurse was transporting a patient to an inpatient unit and RN #3 was providing oversight to the remainder of RN #4's patients while she was off the unit. Interview revealed RN #4 had called and asked RN #3 "to get the blood. I walked directly to the tube station, got the blood and hung it on the pole." Interview revealed RN #3 asked RN #5 to help verify the blood and she had scanned the patient's hospital identification bracelet's bar code while RN #5 began verifying information from the lab bracelet which does not have a bar code identifier, with Patient #2. Interview revealed two nurses "would be typically verifying the (lab) bracelet with the blood order (and) checking paperwork but that didn't happen." Interview with RN #3 revealed a few minutes after starting the transfusion "there was another unit and we thought it was a second unit until we looked and saw it was the patient's blood and the hanging blood was someone else's." RN #3 stated we should have looked at the paperwork that came with the blood and paid more attention.

Interview on 07/15/2020 at 1545 with RN #9 revealed she had been a nurse in the facility's ED for four and a half years and was aware of the "blood incident." Interview revealed some staff were unaware that scanning the unit of blood did not create a "hard stop" if it was "not the correct unit."

Interview on 07/15/2020 at 0900 and at 1600 with the ED Manager, revealed he had managed the ED for 18 years. The ED Manager revealed scanning a blood product into a record simply prevents a transcription error but does not verify the blood product is the correct one for the patient. Interview revealed patient and blood product information must be visually verified by staff, and RN #3 and RN #5 had failed to perform parts the visual verification for Patient #2. Interview revealed that when the nurses involved in the mismatched transfusion were questioned, one had indicated she used "EPIC for verification and the other said you couldn't use EPIC for verification." Interview revealed the same preceptor trained both staff on the transfusion protocol.

Interview on 07/16/2020 at 1340 with the CNO (Chief Nursing Officer) revealed senior leadership was aware that it remained possible for two staff to circumvent visual verification of required information prior to initiating a blood transfusion, but new adjustments to the process were being initiated.

NC00166250, NC00166355, NC00160955, NC00161689, NC00166345