A diabetic 75-year-old woman came to a Houston, Texas, emergency room last year with brain bleeding, anemia and other medical problems.
But what killed her was a botched blood transfusion that staff at Baylor St. Luke’s Medical Center gave her Dec. 2 after transferring her to intensive care, according to a federal government report on the hospital. Her medical team hoped the transfusion would treat her anemia, the report said.
She got the transfusion that evening, and by midnight she had blood in her urine, the report found. By 4 a.m. the next day, the woman’s blood pressure had plummeted, and “a blood transfusion reaction was suspected,” according to the report.
Doctors’ notes said the woman grew critically ill and required “30 units of various blood products” as well as intravenous medication and intubation to help with breathing. Within hours, she went into cardiac arrest four times — and after the fourth, her family “decided to withdraw care,” the report said. The woman died just before 1 p.m. on Dec. 3, according to the report.
The report described the situation bluntly.
“Based on records review and interviews, the hospital failed to administer blood products to patients in a safe manner,” the report said. “As a result, [a patient] received the incorrect blood type and died.”
The hospital’s leader said in an open letter that the report details care “that simply does not meet our standards or expectations.”
“It is our responsibility to learn from these mistakes, and we take this responsibility very seriously,” Doug Lawson, president of the hospital, wrote in the letter Tuesday sharing the findings of the investigation into the hospital. “An incident like this should never happen.”
The report said numerous failings led to the botched and deadly transfusion.
After the patient died, the hospital’s root cause analysis found that the blood sample the emergency room sent to the lab wasn’t from the woman, but from another patient: “The specimen tube in the [hospital] room already had a patient label on it,” the report said, but a “second label was placed over the blood ... and sent to lab.”
Later in the transfusion process, hospital staff “failed to recognize possible signs and symptoms of blood transfusion adverse reaction” and “failed to check vital signs during a blood transfusion” as they should have, the report found.
The report also said the hospital’s deficient practices “had the likelihood to cause harm in all patients who had blood laboratory test drawn in the hospital” — and investigators said they found 122 instances of mislabeling or other labeling problems on laboratory specimens from September 2018 to Jan. 9.
Those errors came close to harming others as well, like when another woman came to the emergency room days earlier and the hospital put in a blood transfusion request for her, but with a blood type meant for a different patient — a mistake the lab caught in time, the Houston Chronicle and ProPublica report.
According to the Chronicle and ProPublica, the government findings on St. Luke’s come “after a yearlong investigation by the Houston Chronicle and ProPublica that documented numerous lapses in patient care at a hospital once regarded as among the nation’s best for cardiac care.”
“These are really basic errors that I didn’t really think happened that often anymore,” said Dr. Ashish Jha, director of Harvard University’s Global Health Institute and a hospital quality expert, according to the Chronicle.
Transfusion mishaps are extremely unlikely on the whole, according to a University of Wisconsin Health information page on blood transfusions.
“Getting the wrong blood type by accident is the main risk in a blood transfusion, but it is rare. For every 1 million units of blood transfused, getting the wrong blood type happens, at the most, 4 times,” the webpage says. “Transfusion with the wrong blood type can cause a severe reaction that may be life-threatening.”