HOUSTON – At the beginning of December, a nurse from the Anderson Cancer Center at the University of Texas supplied a 23-year-old leukemia patient with a blood transfusion contaminated with bacteria without the medical staff's knowledge.
The patient's blood pressure soon dropped, but there is no indication that anyone in the country's high-level cancer hospital was actively monitoring their vital signs at crucial moments during and after the procedure. This resulted in an investigation of the federal government. She died just over a day later.
The potentially preventable death brought a harsh rebuke from the Centers for Medicare and Medicaid Services, whose subsequent investigation on Monday revealed that systemic safety was being exposed in the hospital. The nurses did not properly monitor patients' vital signs when administering blood transfusions, not only in the case of the deceased patient, but also in 1
Since receiving the federal report last month, hospital managers have made changes to improve the nurses' education and to require hourly patient checks during transfusions.
Our patients, not only in the fight against cancer, but also to create the safest and highest quality environment for their care, "said Rosanna Morris, senior hospital officer, in an interview on Tuesday." This event only helps to smooth us out. Better.
But death raised a question that unsettled advocates of patient safety: How can such errors occur in the most prestigious hospitals over the last three decades despite advances in technology and safety protocols?
Deadly blood transfusions are so rare and preventable that they are among a class of medical errors that experts say should never occur. Included in the list of so-called never-events: leave medical devices in a patient after surgery. Operation on the wrong patient or on the wrong part of the body. Give patients contaminated medications.
Such tremendous mistakes may shock the public, Peter Pronovost, a leading expert in hospital security and head of clinical transformation at Cleveland University Clinics.
"What do you mean? Can I get a contaminated transfusion? What do you mean by operating on the wrong part of the body or the wrong person? "Said Pronovost. "Unfortunately, the reality is that these things still happen and we need to install better systems."
Blood transfusions are a hallmark of how hospitals can improve outcomes and prevent errors, Pronovost said. Tens of thousands of people across the country receive daily platelets, plasma or red blood cells to fight disease or replace the lost blood during surgery. In most cases, the procedure is life-saving.
"It's risky," Pronovost said, "but incredibly safe."
Of 17 million blood transfusions in 2017, 37 patients died as a direct result of the Food and Drug Administration. Most of them died of allergic reactions or other complications, but in five cases, the patients received platelets contaminated with bacteria and in seven cases the wrong blood type.
Transfusion deaths have become rarer in the last two decades with the advent of barcode technology, which ensures that patients always receive the correct blood type and strict protocols to detect side effects before patients become critically ill.
However, these precautions only work if hospitals prioritize them, said Erica Mobley, Leapfrog Group Director of Operations, evaluating hospitals for safety issues. She said that too many hospitals still do not, with volume overriding quality and vulnerable to patients.
"In many cases, it's a system error when these terrible errors occur in hospitals," Mobley said. "Man will inevitably make mistakes, but there should be systems that prevent them from causing damage."
Experts say it's important to track a patient's temperature, blood pressure, and heart rate during a transfusion to help medical personnel identify side effects early, and in most cases stop the procedure before a patient is seriously harmed. This is not the case with MD Anderson.
The news of death shocked some hospital security experts as MD Anderson is considered one of the best cancer centers in the country. The hospital annually attracts patients from around the world to its shining facilities in Houston. The death came two months after one of the hospital's top researchers received the Nobel Prize in Medicine for his work on developing a revolutionary treatment that uses the immune system to attack cancer cells.
"These defects were classified as such. Anderson's President, Peter Pisters, on 3 June, severely curtailed your hospital's ability to provide adequate care.
In interviews with regulators, many of MD Anderson's nurses did not seem to understand that they should monitor patients regularly while giving them blood, leaving the vital signs of several patients uncontrolled for hours, both during transfusions and in the subsequent ones hours.
A nurse explained that these patients were trained to recognize signs of side effects, and that it was their responsibility to notify the nurses if something seemed to go wrong: "We educate patients about transfusion" said the unidentified nurse, according to the report. "Patients know they need to call."
MD Anderson's staff also routinely failed to educate patients about potential risks associated with transfusion. In several cases, they relied on informed consent letters that patients had signed months or even years before.
The hospital submitted a correction plan last month that promised changes to the training and patient examinations. In addition, the hospital announced that it will set up a unique command center that will continuously monitor the vital signs of every patient receiving a transfusion in the hospital.
"As a learning organization, we welcome and sincerely welcome you. This is an opportunity to not only improve some of our existing policies and procedures, but also to improve our work and create new best practices," said Morris, COO of Hospital The MD Anderson lab processes blood used for transfusions. This is clear from another letter sent to the hospital this month. This report has not yet been published, and it is unclear whether hospital technicians could or should have detected the bacteria-infected blood that led to the death of the woman.
The Food and Drug Administration requires laboratories to study platelets for bacterial contamination prior to transfusion, but experts say the methods are not very easy.
"Technology works frequently, 76 to 80 percent of cases can detect if a blood product is contaminated, but there are no systems we know That works 100 percent today," Morris said.
Other problems are more easily prevented. The same week that the patient died at MD Anderson, a 75-year-old woman received a transfusion with the wrong blood type at Baylor St. Luke Medical Center, a hospital across the street that had long been regarded as one of the country's hospitals was best for heart surgery.
In this case, medical personnel had bled an emergency patient but did not discard the sample after this patient had been sent home. The vial was left in the hospital room when the staff brought in the 75-year-old who had been taken by ambulance to St. Luke. When a doctor ordered a transfusion for them, the staff accidentally sent the tube containing the blood sample from the previous patient and put a new label over the original.
The patient died the next day after suffering a cardiac arrest.
The Mistake That According to an inspection report published in February, she killed her when she followed a pattern of blood-marking errors at the Houston Hospital.
"These are really basic mistakes that I thought were less common," Dr. Ashish Jha said then, the director of the Global Health Institute of Harvard University.
After the failure, the hospital's board dismissed three top executives and promised to carry out comprehensive reforms that are now underway.
Our responsibility to learn from these mistakes, and we take this responsibility very seriously, "wrote the president of the hospital, Doug Lawson, two months after death in an open letter. "Such an incident should never happen."