Safety Failures At MD Anderson Led To Fatal “Never Event” Blood Transfusion Infection

A federal investigation suggests that safety problems at the MD Anderson Cancer Center resulted in an infection and death following a blood transfusion at the renowned University of Texas hospital.

The U.S. Centers for Medicare and Medicaid Services (CMS) released a report (PDF) on June 26, detailing the results of an investigation in a patient’s death, highlighting several problems that resulted in the “never event”, which experts widely agree should not occur under any circumstances.

The investigation by CMS was conducted from March 29 to April 5, and May 13 to May 17, following the infection of a leukemia patient in December, after undergoing a blood transfusion. That patient died from the blood transfusion infection, which was caused by contaminated platelets.

That kind of infection and death is considered a “never event” by medical experts, meaning that if a hospital is taking the proper basic precautions, it should never happen. The fact that the MD Anderson is considered one of the leading cancer hospitals in the United States raised the concerns over a so-called never event occurring there even higher.

“Never events” are characterized as surgical errors that should not occur during or after surgical procedures, if the proper standards of medical care are followed.  These events could include conducting surgery on the wrong patient, operating on the wrong part of a patient’s body or leaving foreign objects, such as sponges or medical equipment, in wounds. These mistakes often lead to further complications following surgery, and cost the health care industry an estimated $1 billion annually.

The Statement of Deficiencies by CMS investigators found the handling of patient rights, nursing services, laboratory services and other areas out of compliance at the facility. Investigators looked at 33 patient cases and found hospital failures in 18 of those cases.

Many of the concerns focused on the nursing staffing and training at the facility. Investigators found a number of nurses had not completed current annual competency testing or training, and also determined that the facility’s staffing levels were based on budget and not patient safety and failed to reach minimum recommended levels.

The investigators noted the facility was short-staffed on registered nurses for 18 of 21 days reviewed and was short on patient care techs on 17 of 21 days reviewed.

On June 25, MD Anderson issued a press release addressing the hospital’s failings, saying that it was dedicated to addressing the problems and improving.

“While it is unfortunate that the CMS surveys resulted from a patient death, we recognize and embrace the opportunity to further enhance and improve our patient care efforts and robust safety measures,” the press release states. “We take this feedback seriously, and we already have implemented changes into our clinical practice.”