State Seeks Revocation of Licenses in Blood Mix-Up

State health officials have recommended revoking the licenses of two San Diego County hospital employees who botched two blood transfusions, 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 the agency decided not to take action against Alvarado Hospital because inspectors determined that the flawed transfusions were not the result of any systematic failure in the Alvarado medical lab.

Department spokeswoman Betty Hite said the department will 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. Neither technician could be reached for comment.

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

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 May, 1991. The lab gave him a unit of blood with an incompatible antigen, and health inspectors blamed the mismatch on Limiac, a part-time worker at the lab.