Hospital Cited In Transfusion Error
POSTED: Thursday, May 22, 2008
UPDATED: 6:57 am EDT May 23,
2008
ORLANDO, Fla. -- A Central Florida hospital was cited by the state after a patient died in March following a transfusion error.The unidentified patient died March 14 at Orlando Regional Medical Center, but the hospital said in a statement released on Thursday that the report by the Agency for Healthcare Administration does not directly link the death to the transfusion error.The hospital did say that new procedures have been put in place to prevent this type of incident from occurring again.According to the report, a patient in the emergency room required O-positive blood, and after a proper initial dosage was given, two more units were requested. The patient was then given two units of A-positive blood that was left over from another patient, the report said.Eight units of Type A blood were prepared for the other patient but only six were used, the report said. The report by the Agency for Healthcare Administration reveals that there was "no documentation of what was done with the additional two units of blood."Less than an hour later, the patient requiring O-positive blood arrived at the emergency room and was later given the wrong type of blood, the report said.The patient was sent to a trauma room, where the assistant nurse manager described the patient as "bleeding profusely ... all over the room ... had never seen a patient bleed that much," the report stated.When doctors ordered more blood, the nurse realized the transfusion error, the report said. The ID tag for the Positive-A blood was found on the floor, and another nurse who hung the blood did not notice it was the wrong type because of the missing tag, the report stated.The patient died several hours later.The hospital told Local 6 News that the transfusion error was not the cause of death, but the report released on Thursday by the state concluded that the "suspected transfusion error" was linked to immediate hemolytic reaction.Local 6 News reported that medical research shows that uncontrollable bleeding is a common -- and sometimes the only -- sign that something has gone wrong and that hemolytic reactions are often caused by human error, which is what is outlined in the state's official report of what happened at ORMC.A representative for ORMC said no disciplinary action has been taken against any one individual, but the hospital has responded to the state with a plan of corrective action.The state is asking for policy and procedure revisions when it comes to the storage, retrieval, logging and verification of blood.Watch Local 6 News for more on this story.
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