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.
In response, 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. 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 Patient A. RN 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. RN states that because the blood was received in the afternoon, he immediately assigned the transfusion to the primary nurse caring for the patient. RN states that he and the primary nurse went over the blood bank paperwork, and the paperwork matched Patient A. RN states that the Patient A’s vitals indicated the hemoglobin count was at seven (7), which could require a transfusion. 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. RN states that once the transfusion was completed, the primary nurse was on the computer to input his notes and called RN saying there was no order in the computer for the transfusion, and he couldn’t input his notes without the order being there. 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. RN states that due to the verbal report from the day shift manager at shift change, he input the verbal order for the blood. RN states that Patient A had no reaction to the transfusion. RN states that just before shift change, the primary nurse asked if another patient’s blood had been delivered. RN states that there was no other blood, and he was told by the day shift manager only of the one transfusion. RN states 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. RN states that at this time it came to light that it was not Patient A who received the order for the transfusion, but another patient. 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 Patient A instead of the patient she had received the order for. 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. RN states that he admits that he did not collaborate with the physician, at the time transfusion was given. RN states 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 stressed or anxious if you find yourself in a similar situation as that of the RN mentioned above. All you need to do is to find the right RN/LVN license attorney who can help you in the 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 is an experienced nurse attorney for various licensing cases for the past 16 years and represented over 300 nurses before the Texas BON. Contact the Law Office of Yong J. An 24/7 through text or call at (832) 428-5679.