HospitalInspections.org

Based on record review and interview, the facility failed to obtain hourly vital signs during a blood transfusion for 1 of 2 records reviewed (Patient # 5).

This failed practice has the potential to put patients at risk for blood transfusion reactions.

The policy titled "Blood and Blood Product Administration" did not contain steps for administering Packed Red Blood Cells.

The document titled "Clinical Transfusion Practice Guidelines for Medical Interns" by World Health Organization under the section "Monitoring the Transfusion" says for each unit of blood transfused, monitor the patient: before starting the transfusion (baseline observation), 15 minutes after starting the transfusion, at least every hour during transfusion and carry out a final set of observations 15 minutes after each unit has been transfused.

On 03/31/17 at 06:21 a.m., an order was written to transfuse Packed Red Blood Cells.

On 03/31/17 at 08:30 a.m., the "Issue/Transfusion Form" shows product as Red Blood Cells. The transfusion started on 03/31/17 at 08:30 a.m. and ended at 11:05 a.m.

~ Pre Transfusion Vital Signs: Time: 08:15 a.m. BP: 114/55 Pulse: 63 Temp: 98.6 Resp: 16
~Vital signs 15 min after start: Time: 08:30 a.m. BP: 112/53 Pulse 63 Temp: 98.9 Resp: 16
~ 1 hr after start: No vitals listed
~ 2 hr after start: No vitals listed
~ 3 hr after start: No vitals listed
~ Post Transfusion: Time: 11:05 a.m. BP: 110/62 Pulse: 60 Temp: 98.9 Resp: 16

On 08/15/17 at 11:00 a.m., Staff B stated the vital signs should have been completed 15 minutes after start; and the hourly vitals were not in the computer.

On 08/16/17 at 10:30 a.m., Staff C and D stated the process for obtaining blood transfusion vital signs were 5 minutes before starting blood, 15 minutes after start of transfusion, hourly during transfusion and post transfusion.