Texas Woman Died After Hospital Gave Wrong Blood Type in Transfusion

A Texas hospital patient died in December after being given the wrong blood type during a transfusion operation, medical officials have said.

In a deficiency report, top staff at Houston's Baylor St. Luke's Medical Center released a timeline of events that led to the death of the 75-year-old woman first admitted to the facility on December 2, 2018. She showed signs of bleeding into areas surrounding the brain.

According to the detailed analysis of the tragic event, staff decided she did not need surgery but should instead be given a packed red blood cell transfusion. The patient's blood type was B+, but the blood that was transfused was A+.

According to the report, she received the wrong blood type due to the "mislabeling of blood specimens by facility staff." A cascade of errors included: the mislabeling of samples; drawing samples without a physician order; failing to dispose of samples from discharged patients; the failure of the laboratory to reject mislabeled samples; and procedural failures of the nursing staff during tranfusion which may have caught early signs of an adverse transfusion reaction.

Ultimately, it was ruled that the dead woman's blood sample was mixed up with that of another patient in the emergency department room. The woman died the next day due to severe complications caused by transfusion reaction, after suffering four cardiac arrests. The woman was not named in the hospital's report.

In a letter published online yesterday, Baylor St. Luke's Medical Center President Doug Lawson, PhD conceded that the results of the in-depth internal study had been “deeply disappointing.” He said the timeline described in the report “simply does not meet our standards or expectations.”

He wrote: “These findings are the initial results from a review by the Centers for Medicare & Medicaid Services (CMS) of a patient death following a blood transfusion error in the Emergency Department. CMS reviewers found significant deficiencies that led to this incident in December. It is our responsibility to learn from these mistakes, and we take this responsibility very seriously. An incident like this should never happen."

He was first appointed as president on January 14. This week, he said that new “major initiatives” were now being put in place. The results of the internal review were highlighted by local media outlet Fox26.

Updated policies include a “stringent verification process in collecting blood samples and the proper labeling of samples to prevent an error” and the addition of “new safeguards in the hospital's laboratory to not accept blood specimens improperly labeled.”

Lawson promised a refresh of the hospital's culture. He wrote: “Between our internal quality program underway and the forthcoming CMS review, there will be no part of our hospital untouched and no stone left unturned on our journey back to excellence in clinical care.

“This is a challenging time for our hospital. While we cannot go back and change the past, we can focus our efforts on recreating the Baylor St. Luke's you have known and trusted. To our patients, their families, our employees and physicians, and the people of this city… we will take the steps needed to ensure Baylor St. Luke's fulfills our mission of care and compassion.”