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Wednesday, June 27, 2007

She decided to switch beds: Blood transfusion medical error

Tawnya Brown was awaiting bowel surgery in a Northern Virginia hospital when she decided to switch beds to be closer to the window. The move ultimately killed her. During surgery, Brown mistakenly received two pints of A-negative blood. She was O-positive. An investigation revealed that a technician had drawn blood from the wrong patient. Within minutes of the procedure, the 31-year-old suffered a fatal hemolytic reaction, which resulted in plunging blood pressure and kidney failure.

Blood mix-ups, though rare, are still one of the most feared mistakes in transfusion medicine. "It's the biggest threat today," says Dr. Kathleen Sazama, a transfusion expert at the University of Texas M.D. Anderson Cancer Center in Houston. Even an ounce of mismatched cells can trigger a potentially lethal immune response, causing blood clots and internal bleeding.

Advice: Verify the blood type before you receive a blood transfusion.

Read another of our wrong patient stories, or read Michael Stroh’s source story.

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