Transfusion mix-up kills woman in surgery

A woman who swapped beds with another patient in their hospital room so she could be nearer the window died after receiving the wrong type of blood during surgery.

In preparation for the surgery last month, a technician at Inova Fairfax Hospital in Virginia mistakenly took a blood sample from the woman’s roommate, hospital officials said.

Hospital spokeswoman Beth Visioli said today the woman had switched beds, but the death was the result of human error by a hospital employee.

The technician did not follow the hospital’s established procedures for identifying patients, which requires examining each patient’s wristband and having the patient state his or her name.

“The technician doesn’t recall whether she asked the patient her name or not or whether she checked the armband,” Russell Seneca, chairman of surgery at the hospital, said.

“I’m not certain what transpired between the technician and the patient whose blood was drawn.”

The hospital now requires a second person to accompany a technician when blood is drawn as a safeguard against misidentification.

The patient was in hospital for surgery to remove an abscess in her colon. The problem began July 22, when a technician came to the patient’s room to take blood samples the laboratory could use to identify her blood type for the next day’s operation, the hospital said.

During the surgery, the woman was given two pints of the wrong blood. It became clear near the completion of the surgery that her blood was not clotting properly, Seneca said. Later, in the recovery room, the patient suffered a reaction to the transfused blood, which brought about kidney failure.

Doctors struggled to reverse the reaction, but the woman died on July 24.

The technician, described as an exemplary employee, was so distraught that she resigned, the newspaper reported. The hospital is withholding the technician’s name as well as that of the patient.

“We take full responsibility for what happened to this patient,” said Candice Saunders, a senior administrator at Inova.