MD Anderson Issues Plan of Correction after Fatal Blood Transfusion

Jun 29, 2019 | Blood Transfusion, Challenged Sites, Deaths, Federal Inspection, Site Challenges, Site Watch

Professional doctor preparing patient for procedure

MD Anderson has produced a plan of correction after the federal government investigated the patient death that resulted from a blood transfusion.

Click2Houston reports that a 23-year-old female leukemia patient died at the hospital on December 28, 2018, after they received contaminated blood during a blood transfusion. The Dallas Centers for Medicare (CMS) conducted a probe of the prestigious Texas health center.

An unannounced inspection, the federal inspection unit reviewed policies, procedures and documentation related to blood transfusions, including an examination of 34 patients since last December.

Just recently the investigators published a 99-page “statement of deficiencies” delineating a checklist of failures and corresponding corrective actions. MD Anderson didn’t fare as well as they should of for such a prominent, esteemed institution. Deficiencies were identified including:

  • Governing body
  • Patient rights
  • Quality assurance and performance improvement
  • Nursing services
  • Laboratory services

Click2Houston makes the report available here.

As was to be expected MD Anderson staff were fully cooperative with the investigation. It was reported that they were open, honest and ready to embrace any change they needed to make—this is a promising sign. The correction plan focuses on addressing the identified deficiencies including training and monitoring.

MD Anderson Corrections

Some examples include:

  • A new hospital unit providing real-time surveillance of all patients involved with blood transfusions
  • Additional pretransfusion testing of blood products
  • New blood transfusion consent forms every six months or when the cancer diagnoses or chemotherapy changes
  • Ongoing education and online training about blood systems and processes/procedures involving blood transfusions


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