HospitalInspections.org

Based on observation, policy review, and interview, the provider failed to monitor expiration dates of laboratory supplies used for the safe collection of patient specimens in one of one specimen collection area. Findings include:

1. Observation on 9/3/24 at 4:00 p.m. in the laboratory specimen collection area revealed:
*There had been 33 eight milliliter (ml) BD Vacutainer lithium heparin (anticoagulant) blood collection tubes with an expiration date of 8/30/24, stored on the counter with other patient blood collection supplies.
*There had been an additional 50 eight ml BD Vacutainer lithium heparin blood collection tubes with an expiration of 8/30/24, stored in the storage cabinet in this area.
*There had been four 8.5 ml BD Vacutainer ACD-A (anticoagulant/preservative) blood collection tubes with an expiration date of 7/31/24, stored on the counter with other blood collection supplies.
*The expired vacutainer tubes had been available for use to collect patient specimens.
*There had been no additional, unexpired lithium heparin or ACD-A vacutainer tubes available for patient specimen collection.

Review of the provider's 7/30/24 Supplies Quality Program policy revealed:
*Supplies should have been inspected at a minimum of a monthly basis to remove outdated or defective supply products from the supply inventory.
*The laboratory department had not been included in the provider's areas for a monthly inspection.

Interview on 9/3/24 at 4:15 p.m. with laboratory supervisor A revealed:
*The laboratory did not have a policy for checking laboratory supplies for expiration dates.
*The laboratory had not documented when supplies had been checked for expiration, but it should have been done monthly.
*He confirmed the expired 8 ml lithium heparin tubes had been used for collection of patient specimens for blood chemistry testing.
*He confirmed the expired 8.5 ml ACD-A tubes had been used for collection of patient specimens that were sent out for testing.
*He confirmed the laboratory did not have any of the lithium heparin 8 ml tubes or the ACD-A 8.5 ml tubes available that were not expired.

Interview on 9/5/24 at 10:00 a.m. with director of nursing B confirmed that the laboratory was not included in the hospital Supplies Quality Program policy.