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 ...
Please pray for the family.
This appears to be the same case. Very sad; very stupid mistake by the person drawing the blood.
Someone should have checked (and probably triple checked) in the OR as well.
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