State Seeking Suspensions in Blood Mix-Ups : Medicine: Agency wants licenses of two lab technicians revoked. A man died at Alvarado Hospital after botched transfusion.

State health officials on Wednesday recommended revoking the licenses of the Alvarado Hospital employees who botched two blood transfusions since 1989, including one mix-up that contributed to the death of an elderly man just hours after surgery.

But a Department of Health Services spokeswoman said that, after an on-site tour last month, the agency decided not to take action against the hospital itself because inspectors determined that the flawed transfusions were not the result of any “systematic” failure in the Alvarado medical lab.

“The (inspectors) did not believe that there was sufficient cause to call for any action against the hospital,” department spokeswoman Betsy Hite said. “However, they felt that the actions by these two employees were serious enough to warrant permanent suspension.”

Hite said the department will now ask the state attorney general’s office to file a legal complaint to revoke the state licenses of lab technicians Nannette DeLeon and Florante Limiac--a process that could take months if the action is appealed.

Limiac has since quit Alvarado, but DeLeon is still working in the lab, hospital officials said Wednesday. Neither technician could be reached for comment.

In October, The Times reported that the state Department of Health Services allowed the case against the employees to languish for months, although its own confidential investigation showed that they were responsible for the two unrelated transfusion errors at Alvarado.

In the more serious incident, health inspectors concluded that an 84-year-old San Diego man suffered an “adverse and fatal reaction” when he was mistakenly given two units of incompatible red blood cells during open-heart surgery in November, 1989. The man died several hours later, and health inspectors traced the mistake to an “erroneous” cross-match by DeLeon.

An unidentified patient suffered a milder, nonfatal reaction in the second incident in May, 1991. The lab gave him a unit of blood with an incompatible antigen, and health inspectors blamed the mismatch on Limiac, who worked part-time in the lab.

State officials have said that it is highly unusual for one hospital lab to be responsible for two transfusion errors in such a short span of time.

The hospital suspended the technicians for a day after each incident.

The state investigators called for harsher punishment. They urged department administrators to initiate license revocation proceedings, something the state hasn’t done to any of its 19,000 lab technicians since 1989.

But the confidential recommendations were ignored until The Times published the article and the department reopened the cases.

“At some point it bogged down,” Lisa Brandt, the department’s chief counsel, said Wednesday.

Hospital administrators said they were pleased that the state had found no procedural deficiencies in their medical lab, where hundreds of blood samples and patient specimens are cross-matched or analyzed each month.

“We are pleased they confirmed the overall soundness of our system, which was important to confirm in our minds and the minds of the public,” said Gary Sloan, Alvarado’s administrator and chief operating officer.

But Sloan said he still wants to know why the state wants to go after the technicians’ licenses. They said DeLeon will be allowed to continue working in the laboratory as long as she has a valid license.

“We’ll discuss it . . . but honestly we haven’t gotten anything from the state other than their conclusions,” Sloan said. “We haven’t gotten the reasons why” and the state hasn’t told the hospital to take any action.

Michael G. Volz, chief of laboratory services for the state health department and the official in charge of the investigations, declined to elaborate on the reasons why the state wants to revoke the licenses.