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Rare Death from Blood Transfusion at Top Hospital

Most of the time something as routine as a blood transfusion is hardly considered a risk. 

But there are always exceptions.  When there is negligence involved, Theodoros & Rooth takes special interest.

The death of a patient from a transfusion at MD Anderson in Houston sparked a federal investigation that uncovered systemic safety lapses at the hospital, which is considered one of the top cancer centers in the nation.

NBC reported in late June that, “In early December (2018), a nurse at the University of Texas MD Anderson Cancer Center gave a 23-year-old leukemia patient a blood transfusion that, unbeknownst to the medical staff, had become contaminated with bacteria.”

There’s no evidence anyone was actively monitoring her vital signs in the crucial moments during and after the procedure, a federal investigation found. She died a little more than a day later.

The potentially preventable death drew a harsh rebuke from the Centers for Medicare and Medicaid Services, whose subsequent investigation, made public in late June, uncovered systemic safety lapses at the hospital. Nurses were not properly monitoring patients’ vital signs while administering blood transfusions, not only in the case of the patient who died, but also in 18 out of 33 other cases examined, the investigation found.

Since receiving the federal report this month, the hospital’s leaders have made changes to improve training for nurses and require hourly checks on patients during transfusions.

But the death raised a question that has confounded patient safety advocates: Given all the advancements in technology and safety protocols over the past three decades, how can such errors still happen at even the most prestigious hospitals?

Fatal blood transfusions are so rare and so preventable that they are counted among a class of medical mistakes that experts say should never happen. Included on the list of so-called never events: Leaving medical equipment inside a patient after surgery. Operating on the wrong patient or on the wrong body part. Giving patients contaminated drugs.

Such egregious errors can seem shocking to the general public, said Dr. Peter Pronovost, a leading hospital safety expert and the chief clinical transformation officer at University Hospitals in Cleveland.   “The reality, unfortunately, is these things still do occur, and it means we have to put better systems in place.”

Of 17 million blood transfusions in 2017, 37patients died as a direct result, according to the Food and Drug Administration (FDA). Most died of allergic reactions or other complications, but in five cases the patients received platelets contaminated with bacteria, and in seven cases patients were given the wrong blood type.

News safeguards are in place now at medical centers, but those safeguards only work if hospitals make them a priority, said Erica Mobley, director of operations at the Leapfrog Group, which grades hospitals based on safety. She said too many hospitals still fail to do so, prioritizing volume over quality and leaving patients vulnerable.

In interviews with regulators, many of MD Anderson’s nurses did not seem to realize they were supposed to regularly monitor patients while giving them blood, explaining that they checked the patients once shortly after the transfusion began and once afterward. That left vital signs of several patients unchecked for hours at a time.

MD Anderson staff also had routinely failed to inform patients about potential risks associated with transfusions, in several cases relying on informed consent documents that patients had signed months or even years earlier, according to the report.

As we have said many times in this space, the chances are in your favor for minimal risk when undergoing a routine procedure at most hospitals and if the doctors and staff have a solid rating of positive performance.   Still, as in this case, mistakes can be made anywhere.

Theodoros & Rooth has over 110 years of combined experience representing people injured through the fault of others.  If you feel that you or a loved one has been a victim of medical malpractice or most any other area of personal injury, contact us immediately.   We will fight for you aggressively and stand by your side until justice is served.

Sources include NBC News and the FDA