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MEDSTAR WASHINGTON HOSPITAL CENTER 110 IRVING STREET NW WASHINGTON, DC 20010 Dec. 4, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on medical record review, policy review and staff interview, the laboratory staff failed follow the hospital policy for blood collection thereby failing to ensure care in a safe environment for Patient #1.

Finding included...


Record reviews of the hospital's policy titled, "Blood Collections (by Venipuncture) and Transportation," not dated, showed, Positive Patient Identification- A minimum of two patient identifiers must be used to positively identify the patient. For example, name and medical record number or name a year of birth (for outpatient). In-Patients: Verity the patient's identity by checking the NAME and MEDICAL RECORD NUMBER on the wristband against the information on the request label. Review labels before collection to be sre that all attached labels are for the current patient. Blood Bank labels must be detached form any other labels and verified against the name and medical record number separately. If he patients not wearing a wristband or the wrist band information does not match the requisition label information. DO NOT DRAW BLOOD.

The physician admitted Patient #1 with complaints of abdominal pain, weight loss, and loss of appetite and underwent surgical intervention. The physician ordered a type and screen on 10/23/18 at 2:55 PM. The phlebotomist collected a blood sample for type and screen for the procedure on 10/23/18 at 6:00 PM.

The patient typed as O positive. The patient received eight blood products on 10/24/18 and 10/26/18 based on the type and screen; two red blood cell and two plasmas, respectively. The patient tested for more blood on 10/31/19 and typed as A positive- mixed field with A and O positive blood.

According to the written report from the laboratory (lab) Quality Assurance and Performance Improvement (QAPI) Manager, the blood bank checked other samples sent for lab testing and drew the second sample of blood for typing. The original sample retyped and confirmed O positive. All different samples tested confirmed the mixed field. The blood bank determined that the blood sample from 10/23/18 was a mis-draw.

The blood bank determined that Patient #1 retyped as "a true A positive."

The surveyor conducted a face-to-face interview conducted with Employee #3, Manager of the Blood Bank on November 29, 2018, and December 4, 2018. The employee confirmed the process that the Blood Bank completed determining Patient #1's blood type. Employee #3 said the blood bank identified which phlebotomist drew the first blood sample and that the phlebotomist failed to verify the blood sample at the bedside.

The practice lacked evidence that the laboratory staff verified the blood sample at the bedside, thereby not following the hospital's policy and ensuring a safe environment for the patient.