Medical Lab Error Linked to Man’s Death : Health care: Patient died after mismatching of blood at Alvarado Hospital in San Diego, state inquiry alleges. Another mix-up resulted in nonfatal reaction.

Mix-ups in the medical lab of a San Diego hospital resulted in two seriously flawed blood transfusions since 1989, including one where an elderly man died hours after receiving a large amount of incompatible red blood cells, according to a confidential state file obtained by The Times.

A state Department of Health Services investigation alleges that the 84-year-old patient suffered an “adverse and fatal reaction” from the mistaken transfusion at Alvarado Hospital in November, 1989, the file shows.

The file also documents a second major transfusion “error” at Alvarado on May 15, when another patient was given mismatched blood and suffered a milder, nonfatal reaction.

In both cases, health department officials traced the mix-ups to sloppy work in the Alvarado medical lab and recommended taking unusually strong action--suspending or revoking the licenses of the two laboratory technicians responsible.

But the state so far has failed to act on those recommendations, allowing the technicians to continue working. And nearly two years after the first transfusion mistake at Alvarado, state health officials concede they are no closer to deciding what action--if any--to take against the technicians.

“Let’s face it, we didn’t do a good job,” said Michael G. Volz, chief of laboratory services for the state Department of Health Services and the official in charge of the investigations. “We certainly acknowledge that this issue has not been brought to closure in an appropriate amount of time.”

Volz and Alvarado administrators stressed, however, that the incidents were “isolated” and not part of a pattern that threatens public health. Federal and state inspections have repeatedly demonstrated that the Alvarado lab uses the proper procedures to analyze blood and other specimens, they say.

“We’ve reviewed our procedures top to bottom with blood bank specialists and we think we’ve done everything--and then some--to ensure these incidents don’t occur again,” said Gary Sloan, Alvarado’s administrator and chief operating officer.

Sloan and other Alvarado officials also adamantly denied allegations contained in the confidential state file that the hospital’s incorrect transfusion in 1989 killed the elderly patient. But they agreed that it played a role in his death.

“I don’t think you can rule it out,” Sloan said. “Obviously, the transfusion reaction is a contributing factor.”

Whether Alvarado’s 1989 transfusion mistake killed the elderly patient, as state investigators believe, may never be definitively answered, some officials say. No autopsy was performed on the man before his body was cremated and his ashes scattered at sea.

A Times investigation shows that the surgeon who filled out the death certificate--which lists “blood transfusion reaction” as a “significant factor contributing to death”--failed to call the San Diego County medical examiner’s office, which routinely examines cases involving accidental deaths. In addition, the hospital itself failed to immediately contact the U. S. Food and Drug Administration about the mistake, as required by federal health regulations.

“This is going to be one of those inconclusive (cases) because the autopsy is the only thing that could tell you that,” said Mary Ann Touralt, consumer safety officer with the FDA in Washington.

Transfusion-related deaths are unusual, statistics indicate. In 1990, blood banks nationwide reported only 53 such incidents to the FDA, which is charged with conducting follow-up investigations to scrutinize laboratory procedures. Alvarado authorities say the FDA investigated the medical lab and found no procedural problems, but the federal agency Friday declined to release its report.

There are about 2,200 medical labs and 19,000 technicians licensed by the state to perform a wide range of crucial medical tests. Besides cross-matching blood for transfusions, they analyze patient specimens to confirm such conditions as pregnancy, diabetes, syphilis, measles, rheumatoid arthritis, high cholesterol, kidney problems and AIDS.

Public files kept by the Department of Health Services Laboratory Field Services unit in Berkeley show that investigators have reported only minor problems over the years at Alvarado, where 51 employees perform 90,000 diagnostic tests and 1,800 blood cross-matches each month. The minor irregularities were quickly corrected and the lab was recently reissued a license, the public files show. The two bad transfusions are not mentioned.

But a confidential state file obtained by The Times paints a different picture.

“Several oversights on the part of this facility raise questions as to the technical capability of the laboratory personnel,” William S. Argonza, who is in charge of the Laboratory Field Services unit, wrote in a June, 1990, memo summarizing his unit’s investigation into the first transfusion mistake at Alvarado Hospital.

The confidential file says investigators only learned of the 1989 incident when a Health Services Department inspector “overheard a conversation” during a visit to another San Diego medical lab in February, 1990--more than two months after the death of the patient.