Blood Sample Mix-up Led to Patient’s Death at Baylor St. Luke’s Hospital

By Aaron Barker, KPRC Click2Houston.

HOUSTON, TX – A mix-up in blood samples at Baylor St. Luke’s Medical Center last year led to a botched transfusion and a patient’s death, according to a Department of Health and Human Services report released Tuesday.

According to the report, a 75-year-old woman came to the emergency room the morning of Dec. 2, 2018, and was diagnosed with bleeding on the brain. Doctors determined that she would be moved to the intensive care unit and treated with a blood and plasma transfusion. ER doctors ordered a type and screen of the woman’s blood, and she was given a transfusion about 12 hours after she came to the ER.

Early Dec. 3, within a few hours of receiving the transfusion, the woman’s blood pressure dropped and a transfusion reaction investigation was started, according to the report. The woman began suffering multiple medical issues, including four cardiac arrests within the span of three hours. She died at 12:50 p.m.

According to the report, an investigation revealed that the blood samples of the woman and another ER patient were mixed up, which resulted in the woman receiving the wrong type of blood.

Dr. Doug Lawson, who was appointed as the hospital’s president on Jan. 14, said in a written statement that the report found “significant deficiencies” that led to the error.

Lawson said that he has brought in new high-level staff to oversee the corrections and make significant changes at the hospital.

This is the same hospital that was put under the microscope by federal investigators after a yearlong investigation by the Houston Chronicle and ProPublica that showed serious problems that led to a high rate of patient deaths after heart transplants at the hospital.

February 26, 2019

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