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Based on review of the Hospital's Internal Investigation regarding Patient #1 receiving O positive uncrossmatched blood, observations during a tour of the Transfusion Service/Blood Bank work-room, review of Patient #1's Emergency Department (ED)Trauma Record and interviews with the ED Nursing Staff and the Emergency Medical (EM) Attending, it was determined that: A) The Hospital had not fully implemented its Corrective Action Plan prior to the Survey and B) The Internal Investigation failed to identify that the disclosure to Patient #1 was not documented in the patient's medical record

Findings include:

Background information:

The Hospital reported Patient #1 was transferred via a medical flight helicopter to this Hospital from an other acute care hospital after being in a motor vehicle accident and sustaining significant internal injuries. A Code Trauma (activation of a critical care team) was called and during the course of care, Patient #1 received O positive blood. Patient #1 was typed and crossed matched after the transfusions (typing is a laboratory test done to determine a person's blood type and crossmatching is done after the blood is typed to find blood from a donor that the person's body will accept) and Patient #1's blood was found to be A negative. (A female patient who is Rh negative and receives Rh positive blood will develop antibodies. If the patient becomes pregnant, the antibodies may harm a fetus during pregnancy).

Review of the Hospital's Trauma Response Plan indicated that the Blood Bank is notified of the incoming trauma and then releases Trauma (Blood) Coolers.

Review of the Hospital's procedure for related to preparation of the Trauma Coolers indicated that six O positive units of packed red blood cells are placed in one cooler, two O negative units of packed red blood cells are packed in another cooler. Both are released to the ED in the event that transfusion is necessary.

Review of the Emergency Department Trauma Record on 7/14/11 at 9:00 A.M. indicated that between 9:05-9:10 A.M. Patient #1 received 2 1/2 units of packed red blood cells. However, the physician who verbally ordered the blood transfusions was not identified in Patient #1's record.


ED Nurse #1 was interviewed on 1/18/12 at 11:40 A.M. ED Nurse #1 said she was the Primary Nurse during the trauma care. Nurse #1 said her role was to record and document care. ED Nurse #1 said a verbal order was given to transfuse the blood, but ED Nurse #1 did not recall if it was the senior resident or the Emergency Medical Attending who ordered the blood transfusions. ED Nurse #1 said that if the patient is female and under 50 years of age, O negative blood is administered.

ED Nurse #2 was interviewed on 1/18/12 at 12:00 P.M. and ED Nurse #3 was interviewed on 1/18/12 at 12:15 P.M. Both ED Nurse #1 and #2 did not recall the patient, nor the sequence of events regarding the administration of blood to Patient #1. Both ED Nurse #2 and #3 confirmed that O negative blood must be administered to female patients under 50 in an emergency/trauma situation.


A review of the Hospital's Corrective Action Plan that began in September 2011 regarding this incident indicated that the Hospital planned to: develop more vibrant colored visual identifiers on the coolers, develop a check list when uncrossmatched blood is administered which will require a signature from an Attending Physician prior to the administration of blood, a quality review will be performed for all uncrossmatched blood administered, investigate local storage of blood products in the ED utilizing automated dispensing machines and educate physicians and nursing staff on Situation Background Assessment Recommendation (SBAR) communication (a technique of communication that promotes patient safety) during a training program. The Corrective Action Plan was in process, but had not been completed at the time of this Survey. The Hospital's targeted date for implementation was 1/26/2012.

During a tour of the Transfusion Service/Blood Bank work room on 1/18/12 at 10:45 A.M., it was noted that the stickers on the trauma coolers were the same as they were on 7/14/11. The plan to affix more vibrantly colored labels had not been implemented.

The Trauma Surgeon was interviewed on 1/19/12 at 9:10 A.M. The Trauma Surgeon said that on post-operative day #1 or #2 he discussed the risks having received O positive blood with Patient #1's parents and sisters and explained the importance of follow-up with Patient #1's primary care physician.

However, review of Patient #1's medical record indicated that there was no documentation regarding the discussion that took place between the Trauma Surgeon and Patient #1 and her family members regarding receiving O positive blood.

The Nurse Manager of the ED was interviewed during a tour of the ED on 1/18/12 at 11:10 A.M. The Nurse Manager said she was aware there was no verbal order written for Patient #1's blood transfusions. She said the Hospital was in the process of developing a documentation tool that required physician authentication for all verbal orders given during a Code/Trauma. However, the form had not been implemented.


The EM Attending was interviewed on 1/18/12 at 1:20 P.M. The Emergency Medical (EM) Attending said that he was unaware of any verbal order to give Patient #1 blood transfusions.