Virginia hospital blood mixup proves fatal [in surgery, because she switched beds]

Kansas.Com ^ | Fri, Aug. 29, 2003 | Associated Press

[yonif]

FALLS CHURCH, Va. - 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 mistakenly took a blood sample from the woman's roommate, hospital officials said.

Hospital spokeswoman Beth Visioli said Friday that the woman had switched beds, but said 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 in an interview with The Washington Post. "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 hospitalized 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 July 24 about 5:30 a.m., Seneca said.

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.

[WKB]

Let me the first to say it "JUST DAMN"

[LibKill]

What's that sound in the distance?

That really sick demented baying?

LAWYERS!!!!

[VOA]

There is a reason they put that wristband on you in the hospital.

To bad that the folks who are paid to remember that slipped up.

[VOA]

There is a reason they put that wristband on you in the hospital.

To bad that the folks who are paid to remember that slipped up.

[KantianBurke]

Sadly this will become more and more common as the elderly population in this country explodes along with a continued dearth of nurses. Why a shortage? The pay's terrible, the hours are awful and the working conditions are absymal. Those that do get hired are ironically the last types of people you want taking care of your loved ones.

[getitright]

The pay is horrible? Compared to what?

Nurses do quite well in my opinion. And as for the horrible hours- generous shift premiums and weekend/holiday pay help to diminish a number of your points.

Conditions? What place is cleaner and quieter than a hospital?

[KantianBurke]

From what I've seen and read, ER's that are overburdened with "undocumented patients" i.e. illegals that don't speak english or pay, along with nursing homes make the nursing profession leaving a bit much to be desired. And many nurses are working longer shifts at tough times due to the lack of nurses.

[OldFriend]

Hospitals all over the country use window or door as a patient designation. TIME TO END THAT DANGEROUS PRACTICE.

[txzman]

This would not have been a nurse. Hospitals generally use low paid, minimially trained phlebotomists ("blood drawers") to take blood.

She did not however follow very common, very clear, and very loudly expressed lab policy for drawing blood. Everyone who works in a lab understands the issues here loud and clear.

[annyokie]

The pay is pretty generous, IMO. Hospitals are not quiet, however.

[PennsylvaniaMom]

Nurses do quite well in my opinion. And as for the horrible hours- generous shift premiums and weekend/holiday pay help to diminish a number of your points. Conditions? What place is cleaner and quieter than a hospital?

Whoa, where to begin...first of all the blood was drawn by a phelbotomist who probably had to do 8 to 12 draws before returning to the lab; secondly, other than pt. wristband, no chart/info on pt.'s bed (used to be but of course now we all cower to HIPA); third, the pt. may not have spoken english or may have had other concerns (dementia) to complicate the process (still the bracelet should always be checked). I question the thought process of any pt. who would switch beds...linen sanitation is a major issue in hosp. setting. I can think of dozens of reasons why you shouldn't SIT on a pt.'s bed, let alone swap...

Now for your question about nursing...it is no longer pt. care...if you are an RN you are basically an administrator overseeing the LPNs, cert. nurse aides who now do what nurses used to do (pt. care).

[helper]

Oh B/S. INOVA Fairfax Hospital is the best hospital in the area, and perhaps on of the best in the Nation. They were the only one to save the anthrax victims.

The pay is great, the working conditions are excellent. Their cafeteria is almost a work of art.

My wife is a nurse (not at FX HOSP) A few years ago she went to Johns Hopkins Hosp (I am sure you have heard of it) What a pit, I got food poisoning at the cafeteria.
I wondered why none of the Doctors were eating the food except for the prepacked junk in the vending machines. ( Now I know) She almost died because althought the Doctor was Top Notch, after the operation you are left with care by Wanttobe Doctors (Students) and the Nurses were recruited from the neighborhood (the hood).

We had the opportunity to talk to a few good nurses at the hospital that were recruted from Canada. They told us they had no idea how JH was until they got there. They had to live in a compound for safety, and were not happy with the local help. Lots of mistakes and cover ups.

We decided that if we ever had to go to JH for surgery, when ever we were stable we would be transfered to Fairfax Hosp.

It's a very unfortunate mistake, and missed procedures, but in this area Fairfax has thousands of Lawyers on it's door step just waiting for something like this.

In this day and age you almost have to admire the Nurse who made the mistake resigning in a lot of guilt rather than blaming everything, and everyone else.

[joesnuffy]

Conditions? What place is cleaner and quieter than a hospital?

guess you arent on the infection control commitee eh?

[k omalley]

I have worked in hospitals for 36 years and they are not clean and they are not quiet. A hospital is the best place in the world for picking up an infection, many of them are antibiotic resistant.

[Tarheel]

As an RN I have worked double shifts in the ICU because the hospital is short staffed; the patients we care for today in Critical Care would have died ten years ago; the stress is unbelievable; the skills needed, the continuing education and the responsibility for lives are all part of the job.

As far as nurses doing quite well, as you said it is your opinion and you are entitled to it. If nurses did that well and the job was that great we would not have the current nursing shortage that is increasing by the day. Nurses are leaving the profession in droves.

Hospitals are notoriously noisy and as far as cleanliness--that is a huge variable from hospital to hospital. You are obviously uninformed about the huge number of hospital acquired infections.

I venture to guess that any nurse here at FR who has worked in a hospital ER or ICU will concur with the things I have just mentioned.

[radiohead]

I had a co-worker who was pregnant and lived near Johns Hopkins. I was surprised that she hadn't picked it for her hospital (considering the rep JH has).

She told me that it had a lot of students, was not well thought of and just wasn't the place to go if you could avoid it. Among people who lived in the area, it was not first choice.

I was surprised. JH was always held up as being close to the Mayo Clinic, etc. Maybe they're just good for research?

[radiohead]

guess you arent on the infection control commitee eh?

man, i don't even want to go there. when i was clerking in law school, i worked on the very sad case of a girl w/o arms who had gone into a city hospital (i think i'll leave it at that). she had been taught to use her legs for everything.

darned if she didn't get a terrible infection in the hospital that almost cost her the ability to use her legs as well.

my job was to look at all the infection control reports as well as patient complaints (like the lady who came back from the bathroom to find her bed covered w/roaches) and compare them to similar docs from other hospitals.

ain't none of them clean as far as i'm concerned.

[Publius6961]

Switched beds?

[ladyjane]

Nurses do quite well in my opinion

The problem is it's not the nurses who are providing the care and drawing the blood. It's technicians and nurses aides. Hospitals save money by having LPNs and nurses aides doing what nurses used to do. Nurses are now Nurse Managers.