ITHACA, N.Y. — A medical director at Cayuga Medical Center testified Friday in the National Labor Relations Board hearing.

Dr. Daniel Sudilovsky, medical director of laboratory services at Cayuga Medical Center, was the first witness Cayuga Medical Center called as the hearing entered its ninth day Friday. Sudilovsky detailed the hospital’s blood transfusion policy and why it is in place. While several nurses have testified so far that it’s not uncommon for practice to deviate from written policy when giving blood transfusions, Sudilovsky said that information was surprising.

In October, two registered nurses who worked in the Intensive Care Unit at Cayuga Medical Center were terminated for not following blood transfusion protocol and falsifying documents during a blood transfusion Sept. 11, 2016. The hospital said it launched an investigation into the incident after the patient involved complained. Both nurses involved have testified to their side of events already in the case.

Related: Nurse terminated from Cayuga Medical Center testifies in NLRB hearing

Related: NLRB case with Cayuga Medical Center adjourned until Jan. 30; breaking down the case so far

Since the beginning, the nurses have not denied they did not follow proper protocol, but said what they did was common practice in the Intensive Care Unit. What the National Labor Relations Board is determining is whether the nurses were singled out and discharged because of their unionizing activity.

Sudilovsky testified Friday that he considers the Sept. 11, 2016 blood transfusion a “near-miss event.”

The term “near miss” is used in health care and other industries to describe an event that did not result in injury, illness or damage, but had the potential to do so, according to the National Safety Council.

In the Sept. 11, 2016 incident that eventually resulted in the termination of Marshall and Lamb, the correct blood was hung and the patient was uninjured.

Hospital policy states that two nurses must perform a two-tier verification to ensure that the correct blood is going to the right patient, meaning checks must be performed outside the patient’s room and also at the bedside. However, several nurses have testified that typically both nurses do the full checks at the nurses’ station and only one nurse will go in to hang the blood.

Another near-miss incident involving a blood transfusion took place in 2012 and resulted in policy changes. The 2012 incident, referenced a few times during the hearing, involved the wrong blood being spiked, primed and hung for a patient.

In that case, blood was needed for two different patients at the same time. A courier was sent to the lab to get the blood and brought up both units of blood together – something not allowed now in policy – and the wrong unit ended up hung for a patient, though it was caught before being transfused.

Sudilovsky and others in the case have explained that a patient receiving the wrong blood can have fatal consequences. He said “there’s nothing riskier or more dangerous … than flicking the valve open on a unit of blood, potentially.”

After the 2012 incident, the policy was rewritten and nurses were re-educated to be clear that a courier can only transport one patient’s blood at a time, Sudilovsky said.

Sudilovsky said he was concerned when he heard about the patient’s complaint regarding the Sept. 11 blood transfusion. He said the way it was performed “completely ignores and violates the basic safety precautions that we use for the administration of blood products.”

Sudilovsky said in his career, he has never encountered a situation in which a nurse or professional would willfully ignore standard operating protocols designed for patient safety.

“Especially not for something where the potential consequences can be catastrophic,” he said.

Another reason the hospital said it had grounds to terminate Marshall and Lamb was because they falsified documents. The hospital says the nurses falsified patient records by signing on the blood transfusion card that checks had been performed at the bedside when they had actually been done at the nurses’ station.

With more than 2,000 blood transfusion at the hospital per year, Sudilovsky said it’s the only way he knows the blood transfusions are being done correctly.

Raymond Pascucci, who is representing Cayuga Medical Center, asked Sudilovsky if he knew the nurses’ identities when he learned about the incident. He said he did not until later on.

Knowing the nurses violated blood transfusion policy, Sudilovsky said “These are experienced nurses. At this point, as director, I can’t let them touch another unit of blood in this hospital.”

Other nurses in the hearing have testified that they do not follow the policy as it is written every time, with two nurses performing a two-tier check.

Mimi Satter, a legal representative for 1199 SEIU United Healthcare Workers East, asked Sudilovsky if it would surprise him that other nurses have said that it is not uncommon in the Intensive Care Unit for there not to be a two-RN check at the bedside.

Sudilovsky said “Yes” it would surprise him. He said he had never heard of any complaint or any reporting or even any rumors that that was going on. If he had and it could be proven, he said, his reaction would be the same as it was with the two nurses in this case, Marshall and Lamb.

He said if there is substantiated evidence that other nurses are willfully violating the policy, he will not “let them touch another bag of blood.”

Sudilovsky also likened the situation to stealing televisions from Wal-Mart. “Just because everyone’s stealing TVs out of the back of Wal-Mart doesn’t mean the two caught stealing don’t get prosecuted.”

The hearing will continue at 8:30 a.m. Monday at the Administration/CFR building at Ithaca Tompkins Regional Airport. The defense plans to call at least 10 more witnesses, Pascucci said Friday.

Kelsey O'Connor

Kelsey O'Connor is the managing editor for the Ithaca Voice. Questions? Story tips? Contact her at koconnor@ithacavoice.com and follow her on Twitter @bykelseyoconnor.