Blood transfusion mix-up results end in death of Haifa woman

A Haifa woman who received a transfusion of the wrong blood type during surgery at Rambam Medical Center to reset a broken leg died of respiratory and cardiac insufficiency two weeks after the operation.

The incident, reported here for the first time, occurred on December 15, 2008, when Eva Beate Israel, 83, underwent surgery at a Rambam orthopedic surgical ward after falling in her home and breaking her leg.

On Thursday, Israel's family received her medical file from the hospital, confirming the medical error. Family members reported that before she died Israel told them that during the operation, carried out under local anesthesia, she realized that she was being given the wrong blood but was unable to cry out to alert the staff. The hospital reported the incident to the Health Ministry verbally but has not submitted a detailed written report.

Rambam last night denied any connection the between the mistransfusion and the deterioration in her condition, followed by her death.

Blood transfusions are one of the most common and routine procedures performed in hospitals, but also one of the most dangerous. Any error that results in a patient receiving blood of the wrong type can lead to serious injury and rapid death.

According to hospital research studies, an error is made in about one percent of blood typing checks carried out at hospital blood banks. The error can occur because of mislabeling or clerical error at any of several stages in the process.

In the last decade there have been several reported cases of mistransfusion resulting in injury or death in Israel.

Before the accident, Eva Beate Israel was independent and lucid. On December 15, however, she fell and broke her right leg when she got up to use the bathroom in the middle of the night and ran into a chair. She called her son, Ron Israel, who took her to Rambam. Several hours later she was operated on, using an epidural block for anesthesia.

Israel's medical record notes that she needed a blood transfusion, and that two units of blood were ordered from the hospital's blood bank. She received one unit, after the anesthesiologist and the operating room nurse checked the blood type compatibility with the blood bank - all, apparently, according to the guidelines for transfusions.

According to the patient's medical record, however, in the middle of the operation the blood bank informed the operating room that "an error was made in recording the blood units and they do not match the patient's blood type." The record indicates that the patient "was given one unit of blood."

According to the anesthesiologist's report, during the transfusion Israel suffered from shortness of breath for several minutes. She was given oxygen through a mask, and her condition improved.

Two forms, two blood types

Israel's medical record contains two different forms for the blood bank, one listing her blood group as A, the other listing it as B. In fact, she had B-type blood but was given a transfusion of A.

The patient's file notes that the mistransfusion also resulted in bloody urine (an effect of mistransfusion). An expert from the blood bank who examined her noted that she would need large amounts of liquids to maintain proper kidney function, as well as close monitoring of her blood coagulation function. He noted also that she was "cold," indicating a possible circulatory problem.

After the operation, Israel was admitted to the intensive care ward. She was transferred to an orthopedic ward and later to an internal medicine ward. The physician monitoring her there noted that she "felt increasing shortness of breath." He wrote that she also had a lung infection.

Israel's family contacted the Health Ministry's ombudsman through their attorney last week and requested a commission of inquiry to examine the case.

Rambam: No connection

Rambam said last night in response that the attempt to draw a connection between the blood bank's error and Israel's death two weeks after surgery is baseless.

"The patient was an 84-year-old woman who, like many people at her age, had prior conditions including lung and heart disease... The error [in the type of blood supplied by the blood bank] was discovered quickly and the transfusion was stopped shortly after was given," Ramban wrote in its response.

"After the operation the patient was admitted to Intensive Care to monitor possible side effects of the error. None appeared. The unit head personally briefed the patient's family about the error and its circumstances," the statement continued.

"Although it is not required by Health Ministry regulations, the hospital's deputy director immediately reported the incident to Dr. Hezi Levy, the head of the ministry's Medical Administration, and an immediate, comprehensive investigation of the operation rooms and the blood bank was carried out, with the participation of the hospital director.

"The patient was later transferred to the orthopedic ward for further treatment and several days later was transferred to an internal medicine ward. A complication that is not uncommon in elderly surgical patients developed, and unfortunately the patient died two weeks after the operation. Since the death occurred about two weeks after the surgery and was not connected to the transfusion error, it was not reported to the Ministry of Health."