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Based on review of facility documents, staff interview (EMP), and review of medical records it was determined the facility failed to ensure two registered nurses verified the patient's name, date of birth, and blood product prior to the administration of blood resulting in the transfusion of the incorrect blood type for one of six applicable medical records reviewed (MR1).

Review on July 24, 2019, of the facility's policy in place at the time of the complaint, "Emergency Release of Blood and Blood Components Transfusion - For Use Only in the ED, OB, ICU, OR, PACU," last reviewed March 2018, revealed "Policy: Emergency Release of Blood occurs when a patient's life or condition is in jeopardy if blood is not immediately transfused, and the blood is given prior to the determination of the patient's blood type, prior to the completion of the cross match, when the blood is incompatible or when the blood is compatible but an antibody identification has not been resolved. Purpose: To safely administer blood and blood components in an emergent situation. Scope: All emergently released blood and blood products. Procedure: Steps in Procedure 1. The physician will determine the need for emergency release of blood based upon the condition of the patient. 2. The blood bank will be called and notified of the need for emergent release of blood and blood products. 3. The physician will sign the emergency release form from blood bank before the technician will release the blood product. 4. Once product is released two (2) RN's will verify patient name and DOB at the bedside as well as the product numbers and sign the emergency release form as required. 5. Once products are administered a copy of the completed form will be sent to the blood bank and the original will remain with the patient record. ..."

Review on July 24, 2019, of the facility's policy in place at the time of the complaint, "Emergency Release of Blood," revealed "Principle: To provide a process for the provision of blood and blood components before completion of standard compatibility testing of the recipient and when a delay in transfusion could be detrimental to the patient. ... Procedure - Stepwise: 1. When a request for emergency release of blood is received, if the ABO and Rh type was performed, provide type ABO [major human blood group system] compatible blood (per Selection of Blood and Blood Products procedure). When the ABO and Rh [rhesus factor] type is not known, provide O [blood type] negative packed red blood cells. 2. Complete the Authorization for Emergency Release of Blood form. The physician must sign the Emergency release form. Place an "Uncrossmatched [sic]Blood" label on the unit. If the Hollister system was initiated, place a completed Hollister unit sticker on the unit also. Issue the unit(s) of blood. 3. Complete the remaining compatibility testing as per standard operating procedure. ..."

Review on July 24, 2019, of MR1 revealed MR1 was a 33-year-old female and arrived at the Emergency Department (ED) via ambulance on January 8, 2019, at 00:06. There was documentation MR1 was 24 weeks pregnant, had severe bleeding, and was experiencing uterine contractions. MR1's triage note stated she presented to the ED with heavy vaginal bleeding, was pale and shivering. There was documentation MR1's bleeding started in the evening of January 7, 2019, and MR1 had no active bleeding upon arrival.

Continued review of MR1 revealed upon arrival MR1 was placed on the cardiac monitor and was receiving 1 liter of Normal Saline with a pressure bag. OTH1 and OTH2 were at the bedside. There was documentation there were positive fetal heart tones of 142 and positive fetal movement as seen on ultrasound. MR1's vital signs were temperature 97.5, pulse 114, respirations 26, blood pressure 70/40 mm Hg.

Continued review of MR1 revealed physician documentation stat labs were ordered. MR1's hemoglobin was 6.5 and hematocrit was 18.3. MR1's blood type was O positive. There was documentation MR1 was ordered emergent blood transfusion. There was documentation the lab released one unit of blood and the patient was transfused with the unit.

There was no documentation two registered nurses verified the patient name, date of birth, and blood type prior to the administration of the blood. There was documentation MR1 received 1 unit of B positive blood which was intended for another patient in the ED.

There was physician documentation MR1's transfusion was stopped immediately. There was documentation MR1 had no deleterious effects. There was documentation information regarding the incorrect blood transfusion was disclosed to the patient, her mother, and husband.

Continued review of MR1 revealed arrangements were made to transfer MR1 to a tertiary facility. There was documentation MR1 departed the facility via medevac in stable condition on January 8, 2019, at 02:44.

Interview on July 24, 2019, at approximately 11:00 AM, with EMP3 confirmed MR1 received one unit of B positive blood, emergent blood which was intended for another patient in the ED. EMP3 confirmed two registered nurses did not verify the patient's name, date of birth, or blood product prior to the administration of the B positive blood.