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INDIANA UNIVERSITY HEALTH
ADEQUACY OF LABORATORY SERVICES
Tag No.: A0582
Based on document review and interview the facility failed to ensure laboratory services dispensed the incorrect blood product in 1 (one) of 10 (ten) patient medical records reviewed. (P1)
Findings:
1. Review of P1 Medical Record (MR) Nurses Narrative Note regarding Packed red blood cells (PRBC) transfusion dated 07/22/2024 at 1349 hours indicated that the blood arrived on the unit and was verified: blood to patient name band and used two patient identifiers (medical record number/date of birth) by two Registered Nurses. P1 had PRBCs started at approximately 0940 hours, at 1130 hours nurse received a call from the blood bank for the blood product to be suspended due to wrong antigen marker being placed on the blood bag. P1 was transfused a total of 27.6 ml (milliliters) of blood product. P1 received Rh positive blood and needed Rh negative blood product.
2. On 11/27/2024 at 1445 N3 (Laboratory Technician) indicated that the blood bank incorrectly marked the PRBC blood component with Rh negative and released to the PICU to administer to P1.