HospitalInspections.org

Based on record review, interview, and policy review, the provider failed to follow their facility policy to ensure three of four reviewed blood transfusions for two of two sampled patients (1 and 2) had been verified by two staff members to ensure:
*The order had been verified from the patient's chart.
*The identity of the patient had been verified.
*The patient's name and blood identification number from the wristband had matched the tag.
*The donor unit number and type on the tag had agreed with the unit.
*The expiration date had been checked on the donor unit.
Findings include:

1. Review of transfusion records for patients 1 and 2 revealed:
*There had been a total of four transfusions for the two patients.
*Three of the four transfusions did not have a second staff member's signature to verify:
-The order had been verified from the patient's chart.
-The identity of the patient had been verified.
-The patient's name and blood identification number from the wristband matched the tag.
-The donor unit number and type on the tag had agreed with the unit.
-The expiration date had been checked on the donor unit.

Interview on 7/6/22 at 4:45 p.m. with director of nursing services (C) revealed:
*The blood bank transfusion record should have been signed by two staff members before the administration of the blood product.
*She agreed three of the four transfusion records reviewed did not have the second staff verification completed.

Interview on 7/6/22 at 5:45 p.m. with director of quality and risk (B) revealed, that she expected staff to review the above information and perform the second verification before the patients receives the blood product.

Review of the provider's August 2017 Blood and Blood Product Administration policy revealed:
*"1. Two licensed health care practitioners (one of whom must be the RN who will administer the blood product to the patient) will in the presence of the patient perform the following verifications:"
*"2. Verify the patient's name: the patient is asked his/her name and birthdate. The given name and birthdate must match the name on the patient's wrist band and the Blood Bank Transfusion Record."
*"3. Verify the patient's medical record number: compare the medical record number with the following:"
-"a. Patient's wristband."
-"b. Blood bank transfusion record."
-"c. Blood product bag."
*"4. Verify the blood type, the ABO [a group of genetically inherited antigens found in the outer membrane of each red blood cell] group and Rh [Rhesus] type, the unit number, compatibility, and the expiration date on the following:"
-"a. Blood Bank transfusion record.
-"b. Blood product transfusion label.
-"c. Blood product (unit number, product type, and expiration)."
*"6. Verification by two healthcare members (RN [registered nurse], and medical staff) is required prior to administration of blood/blood products."