Family Shattered by Blood Mix-Up; Sterling Patient Died after Error by Inova Fairfax Technician Goldstein, A. Washington Post.

8th September 2003 In July 2003, a patient at Inova Fairfax Hospital of Falls Church, Virginia was transfused with incorrectly matching blood during surgery. The patient Ms. Kathy Brown, who had switched beds with the other patient in the room to be closer to the window was scheduled to have a blood sample drawn by a technician the day before surgery. However, the technician who obtained the specimen did not follow hospital policy to check both the patients identification bracelet and receive vocal identify confirmation; thus, the blood was mistakenly drawn from Ms. Brown roommate, now using Ms. Browns bed. During the following days surgery to remove part of her intestine, MS. Brown, who had O-positive type blood, was transfused with A-negative blood. She died several hours after the surgery, which had initially been perceived as successful. Inovas error attracted considerable local, national and even international media attention. While fellow Washington, D.C-area hospital, Greater Southeast Community Hospital, suffered two deaths of this type in 2002, what made this patient death particularly atypical is the status accorded to Inova Fairfax. The hospital has received a number of accolades for its patient safety and care excellence; it has been recognised as a Magnet institution in Washington, D.C-based American Nurses Credentialing Center and has been included among the U.S. News and World Report Top 50 Hospitals. Writing into the Washington Post, a former Inova nurse expressed her disappointment but not her shock at the fatal series of events, the first recorded transfusion death in Inova Fairfaxs history. Hospital fall-out: The technician, who had a previously exemplary record of service, immediately resigned; the hospital submitted reports to both the Food and Drug Administration and the Joint Commission on Accreditation of Healthcare Organisations. It has not been made public whether further safeguards have been instituted to protect against future specimen errors.