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Lack of Protocol Leads to the Fatal Blood Transfusion of a 23-Year-Old Patient

Photo of Randy Sorrels

On December 8, 2018, a 23-year-old leukemia patient died, two days after receiving a transfusion tainted with a bacterial infection at the MD Anderson Cancer Center in Houston, Texas due to the uncovering of systematic safety lapses. The patient had a history of acute lymphoblastic leukemia and her complications included viral-induced bladder inflammation and the placement of a tube that allows direct drainage from the kidney, so she needed daily blood transfusions. Unfortunately, it was unbeknownst to the medical staff that the infusion the patient received one day was contaminated with a harmful human pathogen called Serratia Marcescens, which is rarely found in blood transfusions.

After the incident was reported, the Centers for Medicare and Medicaid Services conducted an investigation where major shortcomings were discovered with other patient records in addition to the leukemia patient who died from the contaminated blood. It was discovered that no oversight ensured blood transfusions were administered in accordance with policies/procedures and vital signs were not monitored or obtained during transfusions. Additionally, the medical staff failed to make sure that hand-off communication was performed when a patient with an infectious disease was transferred from patient unit to the operating room. Moreover, many patients had no recently signed informed consent documents.

If you or someone you know has been a victim of medical malpractice, contact an attorney at Abraham, Watkins, Nichols, Sorrels, Agosto, Aziz & Stogner by calling 713-396-3964 or toll free at 1‑800-594-4884.

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