https://www.nbcnews.com/news/us-news/no-one-should-die-blood-transfusion-so-why-did-it-n1021506
In early December, a nurse at the University of Texas MD Anderson Cancer Center gave a 23-year-old leukemia patient a blood transfusion that, unbeknownst to the medical staff, had become contaminated with bacteria.
The patient’s blood pressure soon plummeted, but there’s no evidence anyone at the nation’s top-ranked cancer hospital was actively monitoring her vital signs in the crucial moments during and after the procedure, a federal investigation found. She died a little more than a day later.
The potentially preventable death drew a harsh rebuke from the Centers for Medicare and Medicaid Services, whose subsequent investigation, made public Monday, uncovered systemic safety lapses at the hospital. Nurses were not properly monitoring patients’ vital signs while administering blood transfusions, not only in the case of the patient who died, but also in 18 out of 33 other cases examined, the investigation found.
[...] Fatal blood transfusions are so rare and so preventable that they are counted among a class of medical mistakes that experts say should never happen. Included on the list of so-called never events: Leaving medical equipment inside a patient after surgery. Operating on the wrong patient or on the wrong body part. Giving patients contaminated drugs.
(Score: 2) by Runaway1956 on Thursday June 27 2019, @03:14PM (2 children)
With cheese, you can get away with brushing the mold off. You can't do that with blood?
“I have become friends with many school shooters” - Tampon Tim Walz
(Score: 2, Touché) by RandomFactor on Thursday June 27 2019, @03:51PM (1 child)
Hmm, so this blood
- already had its own bacteria
- already has its own coagulant
Yes, I think cheese comparisons are appropriate.
В «Правде» нет известий, в «Известиях» нет правды
(Score: 5, Funny) by fyngyrz on Thursday June 27 2019, @04:26PM
The
Cheese ShopBlood Transfusion Sketch:"Don't you have any blood without bacteria?"
"Ah, well, it's been on order for two weeks, sir. I was expecting it this morning."
"What about monitoring after the transfusion?"
"Well, I'm afraid we don't get much call for it around these parts."
"No one checks on the patients?"
"Ah, not as such."
"What about just plasma? Could we just do plasma?"
"Normally, sir, yes, but today the van broke down."
"You're sure you don't have any blood without bacteria?"
"Never at the end of the week, sir. Always get it fresh first thing on Monday."
"Saline? Could we just go with saline?"
"Ah! We do have some saline, sir.... It's a bit cloudy, sir.... Well, as a matter of fact it's very cloudy, sir.... I think it's cloudier than you like it, sir... Yes, sir." (bends to storage cabinet and reappears) "Oh... the cat's drunk it."
"Will I survive this transfusion?"
"No."
--
You have to be odd to be number one.
(Score: 5, Insightful) by Sourcery42 on Thursday June 27 2019, @05:31PM (5 children)
I do not work in medicine. I do work in a discipline where if mistakes are made and there's a series of unfortunate events people can get hurt or possibly die.
20 years ago I used to see a problem solving mentality that, for lack of a better way of putting it, always boiled down to someone fucked up. This smacks of it. And the sad truth is, that is almost always true. So the root cause of pretty much every investigation used to be that someone fucked up, and they should stop that. There should be a box on a checklist or maybe an alarm in the automation (not an automated response, just a horn or a blinking light or something), maybe a warning in a procedure or some soft administrative control to keep people from fucking up. People simply must stop fucking up. However, the problem is, I already lulled you into complacency with my explanation, and that's exactly what checklists and procedures do. You already stopped reading and started skimming quite a while ago, and I only just snapped you out if it now by pointing it out, if that even worked.
People do fuck up. People are going to fuck up. Again, I don't deal with nursing much, thankfully, but from what I hear they get more than their share of long hours and shitty schedules. When you put people in that position, and expect them to execute on routine tasks over and over and over again flawlessly, you simply cannot rely on them not fucking up as a layer of protection. I'm not necessarily saying that is what happened here. It just kind of smells like it. "No one should ever die from this," sounds like the arrogance I've come to expect from someone who is never going to actually administer this. Combine that with downward pressure from countless bean counters from health care providers and for profit insurance agencies and I bet it is a miracle more people don't end up dead.
More recently I've seen problem solving techniques that pretty much assume people are going to fuck up. There is no root cause. Root cause is in fact a 4 letter word. Failure is inevitable; it is only a matter of how statistically likely you allow failure to become. How comfortable are you knowing that someday someone not dying comes down to one individual manually coding something properly, followed by another manually administering it properly, followed by appropriate follow up monitoring by another grossly overworked individual. The odds of all of those going wrong at the same time are low, but by no means non-existent. Is it really those overworked nurses fault that some 1/100,000 thing fouled up on their watch? Sure they probably got an alarm, but how many meaningless alarms do they get per shift?
(Score: 0) by Anonymous Coward on Friday June 28 2019, @12:05AM (2 children)
The root cause is recreational drug use. The article points it that the nurse in question had tested positive for cannabis usage. So next time you're traveling to a state with legalized marijuana, try to avoid getting transfusions especially if the nurse says "hey man, your blood is so red, groovy".
(Score: 3, Insightful) by Runaway1956 on Friday June 28 2019, @12:21AM (1 child)
I would argue that the root cause is incompetence. It is coincidental that incompetent people rely on drugs to make their lives tolerable.
“I have become friends with many school shooters” - Tampon Tim Walz
(Score: 0) by Anonymous Coward on Friday June 28 2019, @07:57PM
Having known plenty of functional alcoholics, marijuana users, and opiate abuses, I can tell you they are in lots of high stress do or die jobs on a daily basis. The good ones balance it just right so they never fuck up on the job, the bad ones don't.
If a single nurse fucked all these things up, then blame it on her. If she fucked it up because she was high (a seperate issue) then definitely send her to rehab and ban her from doing it with a permanent loss of her credentials if she tests positive.
However, I've found whenever a peasant is taking a fall for something like this, the stink is usually emanating from higher than their position. They are often doing what they need to not take a day off, usually while understaffed and underfunded, and a lot of nurses have substandard coping mechanisms as a result.
I have known a lot of nurses and unless you are 3+ certifications up, you're making pay barely above entry level at most hospitals.
(Score: 2) by Runaway1956 on Friday June 28 2019, @12:19AM
Yeah, and meetings. No matter how good, or how bad, things are going, there has to be a meeting. At the meeting, someone drones on and on about superfluous bullshit, and everyone is lulled into a sense that someone knows what's going on, so everything is good, under control.
I manage to avoid a majority of our meetings, but still get sucked into too damned many of them. Meanwhile, the fuckups continue. I'm sure they would continue even if the fool droning on and on actually understood the problems he/she is trying to address.
“I have become friends with many school shooters” - Tampon Tim Walz
(Score: 0) by Anonymous Coward on Friday June 28 2019, @02:18PM
Fuck-ups will happen but there are ways of reducing fuck-ups and their impact.
Most hospitals have lots of room for improvements.
For example see these and related (search should turn up some): https://www.sportskeeda.com/f1/when-hospital-children-influenced-ferraris-pit-crew [sportskeeda.com]
https://www.telegraph.co.uk/news/1527497/Ferrari-pit-stop-saves-Alexanders-life.html [telegraph.co.uk]
Such improvements can also lead to a reduction in workload. Firstly things are done more efficiently and consistently. since everybody now knows what they are supposed to do, how and when. Whereas before you'd have different people regularly trying to create a different customized order from the chaos. Secondly, whenever you don't make patients worse from fuck-ups you avoid the extra workload from that.