HospitalInspections.org

Based on interview and document review the provider failed to ensure Emergency Department (ED) and Laboratory staff communicated and documented information, regarding one (1) patient's blood specimen, consistent with established policies and procedures.

Findings:

On 4/20/14 at 8:11 am a 45 year old male patient presented to the emergency department complaining of abdominal pain. The ED physician examined the patient and wrote medical orders, including laboratory studies for a complete blood count (CBC).

At 9:00 am the ED nurse performed a venipuncture in the patient's right hand. Blood specimens for laboratory studies were drawn from the site and intravenous fluid was then administered through the site. The RN applied computer generated labels with patient specific identifiers to the specimen tubes. The RN wrote their initials, and the date and time the specimens were drawn, on the patient labels. The specimens were sent to the laboratory. The RN documented the physician orders for the laboratory studies and intravenous fluids were complete.

At 9:37 am the laboratory received the patient's specimens. The receiving laboratory technician noted the CBC was not included with the other specimens received. The technician called the ED and told a nurse that the CBC had not been received. The technician documented the phone call, but failed to document the name of the ED nurse. The patient's ED record does not contain a note regarding the phone call from the laboratory. The laboratory technician cancelled the order for the CBC in the electronic medical record.

At 10:16 am the laboratory received a CBC for the patient. The specimen also had a computer generated label with patient specific identifiers. The specimen label had the date and time the specimen was drawn, but no initials for the staff who obtained the specimen. The laboratory staff entered an order for a CBC in the patient's electronic medical record.

At 10:26 am the CBC report was posted in the electronic medical record system. The results showed decreased amounts for most of the components in the patient's blood, and specifically decreased red blood cells, white blood cells and platelets.

Based on the CBC results the physician ordered a specimen drawn for a blood type and screen, and a transfusion of packed red blood cells. The ED technician drew the blood specimen from the patient's left hand and sent the speciment to the laboratory.

The blood transfusion was initiated at 2:40 pm by the ED RN. The patient was admitted to the hospital at 3:00 pm for observation, repeat blood testing and an oncology consultation.

After the transfusion another CBC was tested. All blood components were within normal ranges after the transfusion.

On 4/21/14 at 9:57 am the hospitalist examined the patient and dictated the Discharge Summary. The hospitalist was suspicious that the initial CBC was erroneous. The hospitalist noted the white blood cells and platelets returned to normal levels without any intervention.

On 4/21/14 at 11:39 am the oncologist dictated a Consultation Report. The oncologist stated that the CBC drawn in the ED was inaccurate. The oncologist speculated the specimen was diluted from the intravenous fluid or the specimen was the result of a poor draw.

The following provider policies regarding laboratory specimens were reviewed:

"Patient Identification", approved 8/12, requires all specimens collected for testing be labeled with the initials of the person who collected the specimen.

"Blood Drawing (Phlebotomy) Procedure", dated 8/10, requires the initials of the person drawing the specimen be written on the specimen label.

"Cancelled/Credited Tests, Policy G19", approved 12/12, requires a phone call to the ordering party when a specimen is not received. The policy also requires the call be documented in the laboratory record system.

"Laboratory Critical Tests/Critical Results/Stats, Policy G 39", approved 2/14, states all ED laboratory orders are stat. The policy also states when calls are placed regarding a cancelled order the name of the person contacted must be written in the laboratory record system.

On 4/25/14 at 10:50 am the ED RN who cared for the patient was interviewed. The RN recalled drawing blood specimens from the patient prior to starting the intravenous fluids. The RN reported labeling the specimen tubes with patient specific labels. The tubes were placed in a specimen bag and taken to the vacuum tube station in the ED by the RN. The RN sent the specimens to the laboratory via the vacuum tube system. The RN recalled a phone call from the laboratory reporting the CBC was not received. The RN did not know the name of the laboratory staff that called, and acknowledged the conversation was not documented in the patient's medical record. The RN reported delegating the task of obtaining the CBC specimen to a specific ED technician. The RN did not follow up with the technician to verify if the task was complete. The patient's medical record does not contain any documentation regarding the delegation of the task to an ED technician. When the CBC results were received, the ED MD and RN discussed the results. The RN stated a call was placed to the laboratory to determine if a type and screen specimen was available for the patient. The RN also received a call from the laboratory that a type and screen specimen was not available. The RN confirmed neither of these conversations are documented in the patient's medical record. The RN delegated the task of obtaining the type and screen specimen to a specific ED technician. The RN acknowledged that facility policy requires documentation of phone conversations regarding patient care, and must specifically include date and time of the conversation and the name of the person spoken to.

On 4/25/14 at 12:30 pm the ED technician who was involved in the patient's care was interviewed. The technician recalled the ED RN requesting a type and screen specimen be drawn for the patient. The ED technician recalled drawing the specimen from the patient's left hand. The technician also recalled that there was a bandage on the inside of the patient's left elbow. The technician did not know who applied the bandage. The patient's medical record documents the technician obtained the type and screen specimen. The ED technician did not recall being requested to draw a CBC from the patient.

On 4/25/14 at 11:45 am the laboratory technician who received the patient's inital ED blood specimens was interviewed. The technician recalled that a CBC had not arrived for the patient with the other specimens. The technician recalled calling the ED, however does not know who they spoke to. The technician documented the call in the laboratory system, but failed to document the name of the person in the ED that they spoke with. The technician acknowledged that facility policy requires the name of the person called.

On 4/25/14 at 12:55 pm the laboratory technician who recieved the patient's CBC specimen on 4/20/14 at 10:16 am was interviewed. The technician stated the only item in the specimen bag was the CBC.

The provider failed to ensure staff followed policies regarding documentation and communication related to a patient's blood specimen.