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Based on hospital policy review, infusion therapy standards of practice review, manufacturers' directions review, facility annual competency review, observation of the initiation of a blood transfusion, personnel file 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 #10), 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:

Review of facility policy titled "Blood Product Administration, General" effective date 12/08/2016, revealed, "...POLICY: Blood products will be administered per national clinical practice standards and in compliance with regulatory requirements... REFERENCE DOCUMENTS... Infusion Nurses Society (INS). (2016). Infusion therapy standards of practice. Standard 62: Transfusion therapy..."

Review of "Infusion Nurses Society (INS). (2016). Infusion therapy standards of practice. Standard 62: Transfusion therapy", as referenced by facility policy, revealed, "...H. Filter all blood components and follow the manufacturers' directions for filter use..."

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

Review of facility annual competency titled, "Blood Product Administration" revised 05/2017, revealed, "...Prime blood administration set for all blood products... with 0.9 % (percent) sodium chloride... Completely cover tubing filter with the fluid when priming..."

Observation of the initiation of a blood transfusion administered to Patient #10 on 08/09/2017 at 1000, revealed Registered Nurse (RN) #3 initiated the blood transfusion without completely covering the blood administration set filter with normal saline prior to initiating the blood product.

Review of RN #3's personnel file revealed RN #3 had completed the Blood Product Administration annual competency on 03/13/2017.

Staff interview conducted with the Director of Nursing on 08/09/2017 at 1110 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.

NC00129468