HospitalInspections.org

Based on review of hospital policy and procedure, medical record review and staff interviews, the nursing staff failed to ensure an informed consent for the administration of blood was signed for 1 of 5 patients who received blood (# 8).

The findings include:

Review of the hospital's policy, "Blood Administration", revised 08/2012, revealed, "...PROCEDURE ...2. A completed informed consent for blood/blood component is required for blood administration except for life threatening situations. The transfusionist is responsible for verifying this consent prior to administering blood/blood components. ...".

Open medical record review of Patient #8 revealed an 80 year-old female admitted on 05/14/2013 with congestive heart failure and anemia. Record review revealed a physician's order dated 05/14/2013 at 2200 for the administration of two units of packed red blood cells. Record review revealed the first unit was started by RN (Registered Nurse) #1 at 2225, completed at 0030. Record review revealed the second unit was started by RN #1 on 05/15/2013 at 0045, completed at 0330. Record review revealed an "Informed Consent for Transfusion of Blood Product" with a section titled, "Blood Transfusion Consent...I give my informed and voluntary consent to the transfusion of blood products if medically necessary, and permit the doctor or such other doctors or persons as may be needed to assist the doctor, to give me the transfusion...". Review revealed no signature by Patient #8 or Patient #8's representative consenting to the administration of blood.

Interview on 05/16/2013 at 1025 with RN #1 revealed, "this happened at the beginning of the shift. I was going too fast. I thought the consent (for blood administration) had been signed. I dropped the ball. We have a checklist for the administration of blood that I failed to follow". Interview confirmed that Patient #8 received two units of packed red blood cells without a prior informed consent. Interview confirmed the nursing staff failed to follow the hospital's policy for the administration of blood.

NC00088257