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Blood mismatch Inova Fairfax Hospital
The Washington Post ^ | 9/8/03 | Avram Goldstein

Posted on 09/08/2003 3:11:18 PM PDT by Belleview

Family Shattered by Blood Mix-Up Sterling Patient Died After Error by Inova Fairfax Technician

By Avram Goldstein Washington Post Staff Writer Monday, September 8, 2003; Page B01

Tawnya Brown sat in her hospital bed and cried, dreading the moment she had hoped would never come. Soon she would undergo surgery to repair damage from an inflammatory bowel disease, which meant wearing a colostomy bag for three months while she healed.

That wasn't how she wanted to live in the Sterling townhouse she shared with her 8-year-old daughter and husband, who can't work full time because of a heart condition.

"I avoided surgery for eight years, and now I'm going to wake up with a bag," she tearfully told a nurse at Inova Fairfax Hospital. But she knew she couldn't hold out much longer. Even before her 31st birthday in early July, she found it painful to move, and she had recently lost more than 10 pounds.

So she swept away the gloom with what her husband called a "big cheesy grin." At 5:30 p.m. July 23, she was wheeled into Operating Room 22, and by 8 p.m. an 18-inch segment of her inflamed, perforated intestine had been removed. The surgeon happily told the family that things had gone well.

But before dawn, Tawnya Brown was dead, her life ended because doctors gave her repeated transfusions of someone else's blood type. The tragic mistake has ravaged Brown's family, triggered an investigation by Virginia hospital regulators, prompted new procedures at Inova Fairfax and brought about the resignation of the technician who the hospital says fouled up.

During the surgery, Brown, who had O-positive blood, received two pints of A-negative blood. Some people die from as little as one ounce of incompatible blood, while others survive such mistakes, medical experts say.

For Brown, the error was compounded when doctors in the recovery room, seeing her unconscious and bleeding profusely, called for more blood. In three hours, they transfused six more pints of the wrong blood type. A person of Brown's size has total blood volume of about eight pints.

"We're taking full responsibility for what happened," said Candice Saunders, a senior administrator at Inova Fairfax. "We took immediate steps to notify the patient's family."

Brown's father, Richard Rally of Sterling, is aghast. "It strikes me as bizarre and beyond comprehension," he said. "I just can't believe it. She said [Fairfax] was the safest hospital. I said, 'You're in the best hands in the world, honey.' That was my last conversation with her."

Brown's husband, John "Butch" Carroll Brown III, wrestled with what to tell the couple's daughter, a third-grader whose name is being withheld at the family's request.

"How do you tell an 8-year-old that her mother's dead?" he said. "They were closer than any two people. . . . They were inseparable. . . . I went home and slept and tried to figure out how I would deal with this. I told her the truth, that her mother was gone and she wasn't coming back. She started crying. I told her crying is something that she'll do. There's not much you can tell anybody in that situation that's really going to help." ........

(Excerpt) Read more at washingtonpost.com ...


TOPICS: Culture/Society; News/Current Events; US: Virginia
KEYWORDS: bloodmismatchinova; fallschurch; hospital; inova
The woman who died from hospital error of mismatched blood was youngb(thirties) with an 8 year old daughter. Previous thread on 8/29 did not reveal name or personal details.

Please pray for the family.

1 posted on 09/08/2003 3:11:19 PM PDT by Belleview
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To: Belleview
Never forget that doctors kill 9,000 times as many people as guns do each year.
2 posted on 09/08/2003 3:13:00 PM PDT by George from New England
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To: Belleview
Wasn't there another blood mismatch death in a hospital within the past 2 or 3 months or is this the same one? The last one, patients switched beds in a room by agreement. Blood was "checked" by where the techie thought the persaon to be operated on was supposed to be and he (she?) got the wrong stuff and died.
3 posted on 09/08/2003 4:58:52 PM PDT by Tacis
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To: Tacis
"Wasn't there another blood mismatch death in a hospital within the past 2 or 3 months or is this the same one? The last one, patients switched beds in a room by agreement. "

This appears to be the same case. Very sad; very stupid mistake by the person drawing the blood.

4 posted on 09/08/2003 5:26:26 PM PDT by Think free or die
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To: Tacis
Patients should not go switching beds without asking the nurses first. I do not see how blaming a techie over the attending nurse who is in charge of a patient, is helping matters. But it's sad either way.
5 posted on 09/08/2003 5:39:27 PM PDT by cyborg (i'm half and half... me mum is a muggle and me dad is a witch)
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To: Belleview
My mother had cancer surgery at Inova Fairfax Hospital in May. Received excellent treatment, despite several complications from the surgery.

IFH is one of the country's top hospitals -- was where the anthrax attack victims in the D.C. area were treated. Nurses/staff work 13-14 hour shifts and look like Zombies after 2-3 days, though. Can see why the mixup occurred.
6 posted on 09/08/2003 5:49:10 PM PDT by quark
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To: cyborg
I do not see how blaming a techie over the attending nurse who is in charge of a patient,

Someone should have checked (and probably triple checked) in the OR as well.

7 posted on 09/08/2003 6:06:34 PM PDT by sistergoldenhair (Don't be a sheep. People hate sheep. They eat sheep.)
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To: sistergoldenhair
Yes I agree... I know there is a chain of command, responsibility,etc. HOWEVER, if I am the surgeon about to operate on someone I'd be combing over everything myself. Come to think of it, so I wouldn't get fired, if I were a techie, I'd check everything myself.
8 posted on 09/08/2003 6:09:14 PM PDT by cyborg (i'm half and half... me mum is a muggle and me dad is a witch)
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To: cyborg
Patients should realize they are often identified by their room and bed in the hospital --- but good nurses and techs always check the identification bracelet and don't go by room and bed or name. It's the one time you really should be happy to be a "number".
9 posted on 09/08/2003 6:12:42 PM PDT by FITZ
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To: Tacis
Had a couple of transfusions last Apr: the nurses used a " Two Man" system just as carefully as a good cryptographic materials custodian handled these sensitive materials. Checked a separate blood typing against my wristband, asked me to confirm blood type, Both checked each plasma packet against the wrist band and one stuck around for quite a while to watch for adverse reactions. Insist on it if you get blood
10 posted on 09/08/2003 6:24:03 PM PDT by RocketWolf
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