No one should die from a blood transfusion. So why did it happen at MD Anderson, the nation’s top cancer hospital?

HOUSTON — 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.

The University of Texas MD Anderson Cancer Center in Houston. Pat Sullivan / AP file

Since receiving the federal report this month, the hospital’s leaders have made changes to improve training for nurses and require hourly checks on patients during transfusions.

“We are unwavering in our commitment to our patients, not only in their battle against cancer, but to provide the safest, highest quality environment to receive their care,” Rosanna Morris, the hospital’s chief operating officer, said in an interview Tuesday. “This event only helps to make us even better.”

But the death raised a question that has confounded patient safety advocates: Given all the advancements in technology and safety protocols over the past three decades, how can such errors still happen at even the most prestigious hospitals?

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.

Such egregious errors can seem shocking to the general public, said Dr. Peter Pronovost, a leading hospital safety expert and the chief clinical transformation officer at University Hospitals in Cleveland.

“What do you mean I can get a contaminated transfusion? What do you mean you operated on the wrong part of the body or on the wrong person?” Pronovost said. “The reality, unfortunately, is these things still do occur, and it means we have to put better systems in place.”

Blood transfusions are considered a poster child for how hospitals can improve outcomes and prevent errors, Pronovost said. Every day across the country, tens of thousands of people receive donated platelets, plasma or red blood cells to combat disease or replace blood lost during surgery. In the vast majority of cases, the procedure is lifesaving.

“It’s risky,” Pronovost said, “yet also incredibly safe.”

Of 17 million blood transfusions in 2017, 37 patients died as a direct result, according to the Food and Drug Administration. Most died of allergic reactions or other complications, but in five cases the patients received platelets contaminated with bacteria, and in seven cases patients were given the wrong blood type.