HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the nursing staff followed the physician's order and the hospital's P&P for a blood transfusion for one of four sampled patients (Patient 4). The physician ordered Patient 4's blood transfusion to be completed over four hours, but it was completed over two hours. The failure had the potential for complications, including transfusion reactions.
Findings:

Review of the hospital's P&P titled Blood Administration and Transfusion dated 11/16/22, showed the transfusion duration ordered by the ordering practitioner is used as a guideline; the actual transfusion duration may vary within 30 minutes.

On 7/14/25, Patient 4's medical record was reviewed. Patient 4's medical record showed Patient 4 was admitted to the hospital on 7/12/25.

Review of the physician's order dated 7/13/25 at 1042 hours, showed an order to transfuse Red Blood Cells (PRBC) over four hours.

Review of the Transfusion Report dated 7/13/25, showed the blood transfusion was initiated at 1216 hours, and ended at 1428 hours.

On 7/14/25 at 1342 hours, Nurse Manager 1 verified the above findings.