Hospital Cited After Patient Gets Wrong Type of Blood : Health: The 60-year-old suffered a reaction but is now doing well. Los Robles Medical Center in Thousand Oaks has revised some policies.

By IRA E. STOLL

May 24, 1995 12 AM PT

SPECIAL TO THE TIMES

A 60-year-old patient at Los Robles Regional Medical Center was mistakenly given almost six pints of the wrong type of blood after a hospital worker mislabeled a specimen--an incident that led federal and state inspectors to cite problems in procedures there.

State regulators investigating the incident in February found that the Thousand Oaks hospital had no proof that a worker responsible for the mistake was properly certified. They also found that the person designated to supervise the part of the lab responsible for blood typing was not a licensed physician, as required by federal rules.

Ken Underwood, the hospital’s chief operating officer, said the patient suffered a reaction to six units of blood but returned home and is now doing well. A human body normally contains between 10 and 12 pints of blood. He declined to release further information about the patient, citing the confidentiality of medical records.

Investigators from the state Department of Health Services descended on the facility Feb. 16, the day after the hospital discovered its error. A second state agency launched a follow-up investigation into the hospital’s blood lab.

Federal authorities, reviewing both investigations, informed hospital officials late last week of more than a dozen deficiencies and gave the hospital 10 days to respond with a plan for correcting the problems.

Underwood called the incident “a regrettable human error.” He said the hospital was taking it “very seriously” and has already revised some of its policies in response to citations from state authorities.

A patient’s reaction to receiving the wrong type of blood varies depending on the particular mismatch, said Dr. Tom Zuck), a former head of the blood division at the federal Food and Drug Administration. Getting the wrong blood during an operation can result in death, Zuck said.

In other instances, especially when the mistake is caught quickly, a patient may suffer only chills and “a feeling of impending doom,” Zuck said.

Zuck, now director of a regional blood center at the University of Cincinnati, said such mistakes happen in perhaps only a few dozen of the 3.5 million blood transfusions each year in the United States.

“It’s exceedingly rare,” said Dr. Toby Simon, author of “Principles of Transfusion Medicine.” He said the mistake is fatal in about 40% of the cases, and that patients who survive may suffer internal bleeding and kidney problems.

Lana Pimbley, district manager for licensing and certification in the state’s Department of Health Services, said, “The concept of giving the wrong blood to the wrong patient is very serious and we take that very seriously.”

Her agency’s investigation reviewed the personnel files of two clinical laboratory technologists at the hospital and found that both had licenses that expired Dec. 31, 1994.

Regulators also discovered that the certification of one of the hospital’s five phlebotomists, technicians who draw blood from patients, could not be verified, and that there was no evidence that the hospital had verified the worker’s certification before putting the person to work with patients. It was that phlebotomist who mislabeled the specimen, Pimbley said.

Underwood said all the hospital’s employees were properly licensed and certified at the time of the incident and at the time of the state investigations.

“That’s very possible,” Pimbley responded. “They couldn’t show us.”

In addition, the state probe found “there were no policies and procedures pertaining to orientation, training, verification of qualifications and competency of staff employed in the clinical laboratory.”

In a subsequent investigation, the state’s Laboratory Field Services Branch found the hospital had been deficient in following its own procedures for specimen labeling. It also found, after conducting interviews and examining hospital records, that the laboratory’s director “delegated the technical supervision of the entire laboratory to a person who does not qualify as a technical supervisor for the specialty of immunohematology.” Immunohematology includes blood typing.

The lab field services investigation also turned up evidence of testing problems in six of 30 tests conducted during a 16-month period for HIV, the virus that causes AIDS.

Investigators found no connection between those mistakes and the patient who received the wrong blood, and there is no evidence that the testing problems affected the outcomes of the HIV tests.

Underwood said the hospital has revised its policies to bring them into compliance with federal rules. He said the hospital’s laboratory is and always has been under the supervision of a licensed physician, but that the hospital “had it listed wrong on whatever policy he was listed in.”

Underwood declined to say if any employees were fired or otherwise disciplined in connection with the matter.

State regulators found out about the incident when hospital administrators reported it to the state, as they are required to do by law.

If the hospital’s plan for correcting the deficiencies is adequate, the institution will likely face no further sanctions, said Karen Fuller, a team leader for the federal health care financing administration. Regulators may visit the laboratory again, however, to make sure the plan is implemented, said Alice Brydon of the state’s Laboratory Field Services.