Late last month, the Houston Chronicle reported that a woman at MD Anderson Cancer Center passed away in December of 2018 during a standard blood transfusion. The patient, who was only 23 years old, was being treated at the center for leukemia. According to reports from the Houston Chronicle and NBC News, the patient was given contaminated blood, resulting in her death. Following this incident, an investigation revealed that this tragedy stemmed from failure to abide by safety protocols. Specifically, nurses failed to properly monitor the patient’s vital signs after the transfusion.
Procedure Deficiencies lead to Poor Health Care
According to the report, the U.S. Centers for Medicare and Medicaid Services (CMS) investigation found several “deficiencies” in procedures that substantially lowered the hospital’s ability to provide adequate care to their patients. The deficiencies that are listed in the public report include severe issues with patients’ rights, quality assurance and performance improvement, nursing services, and laboratory services.
Because of the severity of the violations found during the CMS’s investigation, MD Anderson submitted a plan of correction that will improve their training and patient checks. Until they can prove that they are in compliance with the CMS’s rules and procedures, they will be under federal and state surveillance.
Failure to Monitor Patients
MD Anderson is considered one of the top medical facilities in the country. Given its reputation, it seems almost impossible that something like this could happen. In a report from NBC News, nurses admitted that they often do not monitor patients frequently enough after blood transfusions. They check on them once immediately after the transfusion begins, and then once directly after it is complete. This means that they can miss important changes in vital signs, which we see from this case, can have deadly consequences.
Blood Transfusion Death or Injury should Never Happen
Death or injury resulting from blood transfusions is considered so rare and preventable that they are known as ‘never-events’ in the medical field. These are events that should never happen if medical professionals are meeting the proper standards of medical care. Other never-events include leaving objects inside of a patient after surgery, operating on the wrong site or wrong side of the body, or operating on the wrong patient.
Symptoms of Incompatible Blood Transfusion
Never-events like this are the result of not following basic safety procedures. They are almost always caused by one thing: negligence. In this case, nurses at MD Anderson were negligent when they failed to properly monitor the patient during her blood transfusion. There are obvious symptoms that signal a blood transfusion is going wrong. These symptoms include:
- Chills or body aches
- Changes to blood pressure
- Shortness of breath
- Kidney failure
How Negligence can lead to Blood Transfusion Errors
If nurses had been properly monitoring the patient, they might have noticed these symptoms and been able to take action to prevent the patient’s death. In 18 out of the 33 cases that the CMS reviewed as part of their investigation, MD Anderson nurses’ lack of vigilance played a role in negative transfusion outcomes. Other examples of negligent behavior that may lead to blood transfusion errors include:
- Using the wrong blood type during a transfusion, either because the blood is mislabeled and given accidentally or because the patient’s blood type is not checked beforehand
- Giving the wrong blood to the wrong patient
- Giving patients expired or infected blood
- Delaying or failing to give a blood transfusion
- Improperly administering the blood, including giving too much or too little or sending the blood to the wrong part of the body
- Failing to sterilize equipment
How We Can Help
Blood transfusion complications are labeled as never-events because they should never happen in the first place. These mistakes are preventable as long as medical professionals are meeting the most basic standards of medical care. These mistakes can lead to further health complications, changes in quality of life, and even death. If you or a loved one is coping with the devastating consequences of medical negligence, the person responsible needs to be held liable. At The Brothers Law Firm, we understand your pain and frustration during this time of need. We have represented numerous clients who have suffered as a result of never-event errors like this. We can help you understand your legal rights and determine the best options possible to ensure you and your family get the help you need. To get started, fill out our online form to request a free consultation or call us at 281-491-3635.