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Based on review of documentation and confirmed by staff interviews, two nurses did not follow the Facility's approved policy & procedure for blood transfusions.

Findings included:

A.) The Hospital policy that addressed administration of blood product was reviewed. The Policy stated Check that the product in hand is what was ordered. Verify the blood product with another licensed person: Compare the patient's blood group (ABO/Rh) type on the blood transfusion record (BTR) with the ABO/Rh of the patient on the BTR. Establish that they are identical or compatible as stated by the Blood Bank on the BTR.
Verify patient identity with another licensed person at the bedside by comparing the name and medical record number of the patient's ID band with the patient name and medical record number on the BTR attached to the blood product to be sure they are identical.


B) Review of Patient #1's clinical record indicated Patient #1 was admitted to the Infusion Unit for transfusion of 2 units of A positive blood on 6/16/11. After the first unit of blood had completed infusing, the blood transfusion verification check of the second unit of blood was completed by Registered Nurse (RN) #1, who had been assigned to infuse the second unit and RN #2. Documentation indicated both units of A positive blood were administered and Patient #1 was discharged from the Transfusion Unit.


C) Review of Patient #2's clinical record indicated Patient #2 was admitted to the Infusion Unit for transfusion of 2 units of O positive blood on 6/16/11. Documentation indicated Patient #2 received 1 unit of O positive blood and was then discharged from the Transfusion Unit.

D) Review of documentation indicated RN #3, 16 days after the event, on 7/2/11, reported to a nurse supervisor an incident had occurred on 6/16/11 involving Patient #1 receiving an unknown quality of O positive blood intended for Patient #2.

E) RN #3 was interviewed in person on 9/7/11 at 9:25 AM with the Administrative Fellow present at her request . RN #3 said the error was discovered when she went to retrieve Patient #2's second unit of blood from the refrigerator and only found a unit of blood labeled with Patient#1's name. RN #3 said she immediately told RN #1 of the discovery.

F) RN #1 was interviewed in person on 9/7/11 with the Administrative Fellow present at her request. RN #1 said she had not clearly heard Patient #1's name, when read from Patient #1's ID band, by RN#2 or when Patient #1 reported it, before hanging the unit of blood. RN #1 said she had not reported the incident earlier because RN #2 did not want it reported and behaved in a very threatening manner.

G) RN #3 said RN #2's manner and remarks were threatening and prevented her from reporting the event. RN #3 said she thought since both RN#1 and RN#2 were long time employees of the Hospital, they would do the right thing and report the incident, so she, RN #3, waited. RN #3 said when additional time passed, and neither nurse reported the incident, that is when she reported the incident.

H) Documentation review indicated the Hospital had taken disciplinary action against the nurses involved in the incident. Disciplinary actions included: RN #1 was placed on administrative leave immediately following the discovery of the incident, pending the outcome of the internal investigation. RN #2 was placed on administrative leave, and eventually terminated, after the discovery of an additional, previously unreported incident involving the administration of a medication infusion to the wrong patient. RN #3 was given a written warning.

Based on interview and documentation review, it was determined the Hospital failed to ensure that performance improvement activities tracked medical errors and adverse patient events, analyzed their causes and implemented preventive actions and mechanisms that include feedback and learning throughout the Hospital. Specifically the Hospital failed to ensure that education regarding incident reporting was provided to all Infusion Unit nursing staff following the delay in reporting of two infusion incidents in 1 of 10 clinical records reviewed.

Findings included:

Please refer to Tag A-0409 for additional, background information regarding this incident.

A) The Nurse Manager (Manager) of the Infusion Unit was interviewed in person at various times during the 9/6/11-9/7/11 survey. The Manager said she had met with the nursing staff on the unit in small groups for discussion about the incident, to review staff's knowledge of policies and practices and dialogue about stressors in the environment.

B) Documentation related to the small group meetings that was provided at the Surveyors request, did not indicate the Hospital's incident reporting policy was specifically reviewed, nor did documentation include a signed attendance sheet by attendees at the discussion groups. However, a typed list that included first name and last initial of staff members who had attended a group meeting was provided.

C) Infusion Unit Staff Registered Nurse #5 (RN #5), whose name appeared as an attendee at one of the Infusion Unit group meetings, was interviewed in person on 9/7/11 at 11:15 am. RN#5 said she did not recall any discussion with her about the incident or about any policies or practices.

D) Infusion Unit Staff Registered Nurse #6 (RN#6), whose name appeared as an attendee at one of the Infusion Unit group meetings, was interviewed in person on 9/7/11 at 12:20 pm. RN #6 said the Manager had discussed the incident regarding blood transfusions with her, but there was no discussion about reporting incidents.

E) Infusion Unit Staff Registered Nurse #7 (RN#7), whose name appeared as an attendee at one of the Infusion Unit group meetings, was interviewed in person on 9/7/11 at 11:15 am. RN #7 said she had been away when the meeting took place related to blood transfusion incident. RN #7 said she never attended or spoke with anyone directly, but she heard about the meetings from other staff members.