The Texas Board of Nursing (BON) is known to be very strict when it comes to all actions of nurses, which is why a nurse attorney is needed when attending hearings before the Board. The Texas Board of Nursing does not allow those who wish to exceed the scope of their practice as an RN or LVN.
At the time of the incident, an RN was employed as a House Supervisor at a Hospital in Fort Hood, Texas, and had been in that position for five (5) months.
On or about August 31, 2019, while employed as a Registered Nurse, the RN incorrectly instructed another nurse to administer one (1) unit of packed red blood cells to a patient, without an order. Specifically, the RN received hand-off communication from the outgoing House Supervisor that she had received a verbal order for the patient to receive blood. The RN notified the primary nurse caring for the patient and assisted in initiating the blood transfusion, including signing off on the verification form. The verbal order was intended for a different patient.
Additionally, the RN incorrectly entered the order for the blood transfusion without speaking with the physician. Subsequently, it was discovered the following morning that the patient had received another patient’s blood due to staff using the patient’s room number instead of the patient’s name or medical record number. The transfusion reaction protocol was initiated and the patient required additional medications and monitoring. The RN’s conduct unnecessarily exposed the patient to the risk of harm from the non-efficacious administration of blood products.
In response to the incident, the RN states that he works as the evening shift manager and at shift change on the day in question, he came onto shift and took a verbal shift change report from the day shift manager. The RN states that the day shift manager explained to him that she took an order for the blood transfusion, and handed him the blood for the patient. The RN also states that day shift had ordered the blood due to the anemia of the patient but had not begun the transfusion during the day shift. She also states that because the blood was received in the afternoon, he immediately assigned the transfusion to the primary nurse caring for the patient. Then she states that she and the primary nurse went over the blood bank paperwork, and the paperwork matched the patient. The RN states that the patient’s vitals indicated the hemoglobin count was at seven (7), which could require a transfusion. The RN states that the vitals, blood bank paperwork, the patient’s identification, and other information matched, so he signed off on the blood and paperwork, and ordered the nurse to begin the transfusion. The states that once the transfusion was completed, the primary nurse was on the computer to input his notes and called the RN saying there was no order in the computer for the transfusion, and he couldn’t input his notes without the order being there. The RN states that in order for the primary nurse to enter his notes, the verbal order for the blood had to be entered into the computer. The RN states that due to the verbal report from the day shift manager at shift change, he input the verbal order for the blood.
Furthermore, the RN states that the patient had no reaction to the transfusion. The states that just before shift change, the primary nurse asked if another patient’s blood had been delivered. The RN states that there was no other blood and he was told by the day shift manager only one transfusion. The RN states that at shift change the following morning, the primary nurse and patient’s day nurse discussed the transfusion, and the day nurse inquired whether the other patient had received a blood transfusion as well. The RN states that at this time it came to light that it was not the Patient who received the order for the transfusion, but another patient. The RN states that upon researching what had occurred to allow the wrong blood to be transfused, it was determined that the day nurse made a mistake when ordering blood, in that she ordered blood for the patient instead of the patient she had received orders for. The RN states that because the blood ordering process is a paper-only process, often verbal orders for blood do not get entered into the computer system until after the transfusion is complete and the nurses go to input nursing notes. The RN states that he admits that he did not collaborate with the physician, at the time transfusion was given. The RN states that upon learning there was no order, he did input the verbal order received from the day shift manager’s verbal shift change report to him.
As a result, the Texas Board of Nursing decided to sentence her RN license to disciplinary action to ensure that she will never commit such acts again. The Texas Board of Nursing has full jurisdiction over all cases that may affect the RN license. The strictness of the Board also ensures that nurses will only commit to the duties they are assigned in order to guarantee accurate and excellent performance in all hospitals throughout the state of Texas.
The case would have yielded a different result if the RN was able to hire a nurse attorney. So if you also have the same cases or concerns, it’s best to contact Nurse Attorney Yong J. An for further details. You may contact Nurse Attorney Yong J. An at (832) 428-5679 to get a schedule for a confidential consultation.