75-Year-Old Woman Died After Receiving Wrong Blood Type for Transfusion, Report Finds

February 26, 2019 Updated: February 26, 2019

A 75-year-old patient died after allegedly receiving the wrong blood type for a transfusion she received in a hospital in Houston, Texas, in December last year, according to a report released on Feb. 26.

The patient was admitted to the emergency department (ED) of Baylor St. Luke’s Medical Center after having a brain hemorrhage on Dec. 2, 2018. After receiving a blood transfusion, she started experiencing complications and became critically ill.

The report (pdf) stated that during the blood transfusion the patient, who was blood type B+, received A+ plasma in error. She suffered four cardiac arrests within a three hour period before she died on Dec. 3.

The findings from the investigation, released by the hospital on Feb. 26, concluded that the hospital had not completely cleared the room when the previous patient, identified as patient 28 in the report, was ED discharged. One blood vial from patient 28 was still left in the room when the 75-year-old patient was admitted.

(David Silverman/Getty Images)

The report said an ED nurse failed to correctly label the vial, which resulted in the double labeling of the blood sample. It was this incorrect blood sample that was sent to the lab. As a result of the mislabeling, the 75-year-old allegedly received the wrong blood type, according to the findings.

This incident was among 122 cases where St. Luke’s staff made mistakes involving mislabeling or problems with the labeling of blood samples. The report provided details of many of these incidents.

In an open letter, Baylor St. Luke’s Medical Center President Doug Lawson vowed to take the findings seriously to ensure that incidents like this should never happen again.

“These findings are the initial results from a review by the Centers for Medicare & Medicaid Services (CMS) of a patient death following a blood transfusion error in the Emergency Department. CMS reviewers found significant deficiencies that led to this incident in December. It is our responsibility to learn from these mistakes, and we take this responsibility very seriously. An incident like this should never happen,” he said in his letter.

He also listed a number of corrections the hospital has taken and major initiatives put in place following the incident.

These changes were made in addition to the leadership restructuring, which occurred last month. Dr. Lawson was appointed as president of the hospital on Jan. 14, replacing former hospital president Gay Nord. A few days later several new members of the executive team were also announced.

“This is a challenging time for our hospital. While we cannot go back and change the past, we can focus our efforts on recreating the Baylor St. Luke’s you have known and trusted,” Lawson said in his letter.

“To our patients, their families, our employees and physicians, and the people of this city and region we serve, we will take the steps needed to ensure Baylor St. Luke’s fulfills our mission of care and compassion. I believe we will emerge stronger than ever.”

Follow Janita on Twitter: @janitakan
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