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Based on observation of the initiation of a blood transfusion, hospital policy review, manufacturers' directions review, and staff interview, facility staff failed to administer a blood transfusion in accordance with accepted standards of practice in 1 of 1 observed blood transfusion (Patient #16) by failing to fill the drip chamber of the blood administration set with enough normal saline to cover the blood filter prior to initiating the blood transfusion.

The findings include:

Observation of the initiation of a blood transfusion administered to Patient #16 on 08/17/2017 at 0950, revealed Registered Nurse (RN) #1 initiated the blood transfusion without completely covering the blood administration set filter with normal saline prior to initiating the blood product.

Review of facility policy titled "Blood & Product Administration", last revised date 08/2017, revealed, "...PROCEDURE: I. Administration of Blood Products ...13. Open clamp to saline bag and squeeze and release blood filter until filter is completely covered..."

Review of manufacturers' directions included with the blood administration set utilized by a current staff member revealed, "...DIRECTIONS... 4. Squeeze and release blood filter until filter is completely covered..."

Staff interview conducted with RN #1 on 08/17/2017 at 0950 revealed she believed the drip chamber should be one third full with normal saline prior to the start of the blood transfusion.

Staff interview with the Patient Safety Officer on 08/17/2017 at 0955 revealed she believed the drip chamber should be two-thirds full with normal saline prior to the start of the blood transfusion.

Staff interview conducted with the Director of Education on 08/17/2017 at 1235 and at 1455 revealed covering the filter was an important step in the blood administration. Interview revealed the blood filter should be completely covered with normal saline to prevent damaging of the red blood cells in the filter. Interview revealed facility staff are expected to follow the manufacturers' directions when utilizing equipment in the facility. Interview revealed facility policy was not followed when initiating the blood transfusion.

NC00129223