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Home / Health / Nobody should die from a blood transfusion. Why did it happen in MD Anderson, the country's best cancer hospital?

Nobody should die from a blood transfusion. Why did it happen in MD Anderson, the country's best cancer hospital?



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

8 out of 33 other cases studied.

The University of Texas, MD Anderson Cancer Center in Houston. Pat Sullivan / AP File

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.


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