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Ensuring accurate and safe administration of medications, particularly blood products, is a fundamental responsibility of nurses in healthcare settings. However, mistakes in this critical area can have severe consequences for patients and raise questions about an RN’s fitness to practice. Such an occurrence can lead to compromised patient care and unnecessary exposure to potential harm. When facing allegations concerning medication errors and patient safety, seeking the guidance and support of a nurse attorney can be essential to navigate the legal complexities, protect the RN’s rights, and ensure a fair evaluation of the situation.

At the time of the incident, he was employed as an RN at a hospital in Garland, Texas, and had been in that position for five (5) months.

On or about August 31, 2020, while employed as an RN at a hospital in Garland, Texas, RN incorrectly instructed another nurse to administer one (1) unit of packed red blood cells to Patient A, without an order. Specifically, 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, 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. RN’s conduct unnecessarily exposed the patient to risk of harm from non-efficacious administration of blood products.

The RN deliberately gave his response without seeking advice from a Texas nurse defense attorney first and stated that he worked 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 day shift manager explained to him that she took an order for the blood transfusion and handed him the blood for Patient A. The RN stated that the day shift had ordered the blood due to the anemia of the patient but had not begun the transfusion during the day shift. He added that because the blood was received in the afternoon, he immediately assigned the transfusion to the primary nurse caring for the patient. The RN stated that he and the primary nurse went over the blood bank paperwork, and the paperwork matched Patient A. Patient A’s vitals indicated the hemoglobin count was at seven (7), which could require a transfusion. 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 RN mentioned 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. For the primary nurse to enter his notes, the verbal order for the blood had to be entered into the computer. Due to the verbal report from the day shift manager at shift change, he input the verbal order for the blood. Patient A had no reaction to the transfusion. Just before the change of shift, the primary nurse asked if another patient’s blood had been delivered. There was no other blood, and he was told by the day shift manager only of the one transfusion. The RN stated that at shift change the following morning, the primary nurse and Patient A’s day nurse discussed the transfusion, and the day nurse inquired whether the other patient had received a blood transfusion as well. At this time it came to light that it was not Patient A who received the order for the transfusion, but another patient. 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 Patient A instead of the patient she had received the order for. The RN stated 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 aftert the transfusion is complete and the nurses go to input nursing notes. He admitted that he did not collaborate with the physician, at the time the transfusion was given. The RN stated that upon learning there was no order, he did input the verbal orders received from the day shift manager’s verbal shift change report to him.

The above actions constitute grounds for disciplinary action in accordance with Section 301.452(b)(10)&(13) Texas Occupations Code, and is a violation of 22 TEX ADMIN. CODE §217.11(1)(A),(1)(B),(1)(C),(1)(N),(1)(P)&(3)(A) and 22 TEX. ADMIN. CODE §217.12(1)(A),(1)(B)&(4).

However, without valid evidence to defend his side of the story, the RN lost the case. Furthermore, the RN failed to hire a Texas nurse attorney to help him with his case. Because of this, the Texas Board of Nursing disciplined the RN’s license.

Do not be anxious if you find yourself in such situations as that of the RN mentioned above. Find the right RN/LVN license attorney who can help you defend your case. Equip yourself with the knowledge and expertise you need for a successful outcome by consulting a knowledgeable and experienced Texas RN/LVN license attorney. Texas Nurse Attorney Yong J. An has been an experienced nurse attorney for various licensing cases for the past 18 years and represented over 600 nurses before the Texas BON. Contact the Law Office of Yong J. An 24/7 through text or call at (832) 428-5679.

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