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MEMORIAL HOSPITAL FOR CANCER AND ALLIED DISEASES
MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY
Tag No.: A0347
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Based on document review and interview, the medical staff failed to notify the Blood Bank in a timely manner of a potential transfusion reaction, as per the Medical Staff Rules and Regulations.
Findings include:
Review of Medical Staff Rules and Regulations #226C (Revised 8/30/24) revealed, "The Blood Bank is informed of adverse events related to the administration of blood components occurring at or outside Memorial Sloan Kettering (MSK) ... Procedure: ...
Notify the Blood Bank immediately ... (24 hours a day/7 day a week) for adverse events related to the administration of blood components at MSK. The occurrence is documented in the electronic health record (EHR)."
A review of the medical record for Patient #1 revealed that on 11/21/2024 at 10:00 AM, the patient completed receiving a transfusion of platelets (Blood products). Approximately two hours post-transfusion, the patient's oxygen levels decreased to 60-70% (reference range: 95-100%) during a physical therapy session. The patient was on 100 % oxygen via a Non-Rebreather Mask (NRB). At 12:16 PM, Rapid Response Code/Team (RRT) was activated for Hypoxia (Low levels of oxygen) and Respiratory Insufficiency (A condition that causes problems with breathing, specifically at rest).
On 11/21/2024 at 04:01 PM, six (6) hours after the platelet transfusion, Staff R (Physician Transplant Services) documented the "Transfusion Reaction Work Up order."
On 11/21/2024 at 08:31 PM, the patient was pronounced dead from Cardiac Arrest.
On 05/02/25, at 10:08 AM, during an interview, Staff Q (M.D. Laboratory/Blood Bank Leadership) stated that the case was brought to their attention by the Quality Assurance Leadership, who asked them to investigate the incident.
Staff Q stated that the potential blood transfusion reaction was not reported promptly, and that timely notification was extremely important. Staff Q reported that they became aware of the incident two weeks later during a Quality Assurance review.
On 05/03/2025 at 01:10 PM, Staff S (Nurse Practitioner) confirmed that the Blood Bank was not notified and stated there was no designated person responsible for lab notification of transfusion reactions. Staff S added that this may be the reason why no one reported the incident.