HospitalInspections.org

Based on review of the latest evidence-based research guidance , review of policy and procedure, observations, and staff interviews the facility failed to monitor 2 (Patient 13 and Patient 14) of 3 patients who received blood within the first 15 minutes of administration for signs and symptoms of a blood transfusion reaction and vital signs. This failed practice has the potential to cause harm to any patient experiencing a blood transfusion reaction. The facility inpatient census on entrance was 499.

Findings are:

A. Review of the Lippincott Nursing Procedures (9th edition, 2023), revealed the "latest evidence-based research guidance" for the transfusion of blood and blood products implementation reads, "Remain near the patient during the first 15 minutes to monitor for signs and symptoms of a transfusion reaction, because if a major incompatibility exists, or a severe allergic reaction such as anaphylaxis occurs, signs and symptoms usually appear before the first 50 mL (milliliters, amount of blood product that enters the patients blood stream) of the unit have been transfused."

B. Review of the policy titled, Blood and Blood Components: Administration and Documentation (effective 6/5/2025) revealed "to document the patient's 15-minute vital signs (Start of the transfusion + 15 minutes), and evaluate for possible transfusion reaction."

C. During observation of blood administration by Registered Nurse B (RN-B) on 7/22/2025 revealed the following:
-Patient 13, on neutropenic precautions (body's defenses are weak, high risk for infection), was ordered to receive a transfusion of blood, and had never received blood products before. Observation of RN-B at 10:47AM revealed the patient was prepped for the administration of blood that started at 11:02AM via peripheral intravenous (IV) (a tube that goes into a vein). RN-B left the room and closed the door. At 11:19AM an RN entered Patient 13's room [17 minutes after the blood transfusion started], confirmed by Patient Safety RN.

-Patient 14 was ordered to receive a transfusion of blood. Observation of RN-B at 12:19PM revealed the patient was prepped for the administration of blood that started at 12:28PM via peripheral IV. RN-B left Patient 14's room at 12:30PM. RN-B entered Patient 14's room at 12:50PM [22 minutes after the blood transfusion started.], confirmed by RN-A.

D. Interview with the Patient Safety RN (7/22/2025 at 11:20AM and 12:51PM) confirmed RN-B did not monitor or recheck Patient 13 or Patient 14 for signs and symptoms of a transfusion reaction or obtain vital signs within the first 15 minutes of the blood transfusion start time.