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Based on interview and record review, the hospital failed to maintain the adequate blood product inventory levels as per the hospital's P&P. This failure posed the risk to patient safety.

Findings:

Review of the hospital's P&P titled Blood Product Inventory Management dated 9/16/24, showed in part:

* Scope: Trained Blood Bank Staff.

* Purpose: It is the responsibility of the Blood Bank Technologist on all shifts to maintain the adequate blood product inventory levels to meet the needs of our patient. The CLS will provide adequate supplies of blood for routine and emergency use while minimizing outdating.

* Policy: The CLS will provide adequate supplies of blood for routine and emergency use while minimizing outdating.

* Procedure:

B. Ordering Blood Components:

- In cases of blood shortages, blood products may order from American Red Cross (ARC) and San Diego Blood Bank (SDBB). Inventory levels are evaluated and recorded daily.

- Minimum and maximum inventory levels are established (refer to current inventory worksheet) and stock levels are based on the established maximum level.

C. Inventory Levels

1. RBC:
Type Minimum
O Pos 20
O Neg 6
A Pos 20
A Neg 4
B Pos 6
B Neg 2

2. Fresh Frozen Plasma: No Rh preference.
Group O 10
Group A 10
Group B 10
Group AB 4

3. Pooled Cryoprecipitate: No Rh preference.
Group O 1
Group A 1
Group B 1
Group AB 1

5. Liquid Plasma A and Liquid Plasma B are ordered daily for a quantity of five each, if available.

D. Notes:

- If possible, always keep 6 units of Platelets available at all times. If the platelet is down to 3 units make sure to place an additional 3 units ASAP.

On 10/31/24 at 1005 hours, an interview with concurrent review of Patient 1's medical record was conducted with the Blood Bank Supervisor. Patient 1's medical record showed the patient was admitted to the hospital on 9/26/24. Patient 1's medical record showed the patient had multiple blood transfusions on 9/26/24.

Review of the Daily Blood Product Inventory Management form dated 9/23/24, did not show Liquid Plasma A (LP-A) and Liquid Plasma AB (LP-AB) were ordered for a quantity of five each as per the hospital's P&P.

Review of the Daily Blood Product Inventory Management form dated 9/24/24, did not show the adequate numbers of RBC A Negative and A Positive, LP-A, and LP-B were on supply as per the hospital's P&P.

Review of the Daily Blood Product Inventory Management form dated 9/25/24, did not show the adequate numbers of RBC A Negative, A Positive, LP-A, and LP-B were on supply as per the hospital's P&P.

Review of the Daily Blood Product Inventory Management form dated 9/26/24, did not show the adequate numbers of RBC A Negative, A Positive, O Negative, LP-A, and LP-B were on supply as per the hospital's P&P.

Review of the Daily Blood Product Inventory Management forms dated 9/27, 9/28, 9/29, and 10/8/24, did not show the adequate numbers of RBC O Negative were on supply as per the hospital's P&P.

Review of the Daily Blood Product Inventory Management form dated 9/29/24, did not show the adequate number of LP-A was on supply as per the hospital's P&P.

Review of the Daily Blood Product Inventory Management forms dated 10/8, 10/9, and 10/12/24, did not show the adequate numbers of RBC O Negative and LP-AB were on supply as per the hospital's P&P.

Review of the Daily Blood Product Inventory Management form dated 10/27/24, did not show the adequate number of LP-AB was available as per the hospital's P&P.

Review of the Daily Blood Product Inventory Management form dated 10/31/24, did not show the adequate numbers of RBC A Negative, A Positive, B Positive, O Positive, LP-A, and LP-AB were available as per the hospital's P&P.

Review of the Daily Blood Product Inventory Management forms dated 11/1 and 11/2/24, did not show the adequate numbers of RBC A Negative, LP-A, and LP-AB were available as per the hospital's P&P.

Review of the Daily Blood Product Inventory Management form dated 11/3/24, did not show the adequate numbers of LP-A and LP-AB were available as per the hospital's P&P.

Review of the Daily Blood Product Inventory Management dated 11/4/24, did not show an adequate number of RBC B Negative and O positive, LP-A, and LP-AB were available as per the hospital's P&P.

On 11/4/24, the above findings were verified by the Blood Bank Supervisor and Chief Quality Officer.