State Acts on 3rd Mix-Up at Alvarado Lab : Medicine: Revocation of technician’s license sought after injection of blood cells into wrong patient.

California health officials want to revoke the license of an Alvarado Hospital nuclear medicine technician who injected radioactive white blood cells into the wrong patient last month, a spokeswoman for the Department of Health Services said Monday.

Spokeswoman Betsy Hite said the Oct. 5 mix-up was caused by human error on the part of the unidentified technician, who admitted to a health department investigator that he misread the patient’s identification wristband before injecting treated blood cells intended for another patient.

“There are clearly procedures in place for looking at the (name on the) armband and looking at the syringe,” Hite said. “They should all match. It’s not a difficult thing to check.”

Monday’s announcement means the state is taking action against three Alvarado technicians responsible for botched medical procedures at the College area hospital.

In January, the department asked the state attorney general’s office to prepare formal “accusations” against two medical lab technicians who mismatched separate blood transfusions, including one that contributed to the death of an elderly patient just hours after heart surgery in November, 1989.

The health department’s decision to go after the licenses came three months after The Times revealed that a confidential state investigation into the bad transfusions had been allowed to languish, though health inspectors concluded that the elderly patient suffered an “adverse and fatal reaction” after receiving two units of incompatible red blood cells.

Dennis Eckhart, a supervising deputy attorney general, said Monday that his office would finish the written accusations against the medical lab technicians in two weeks.

Once the lab technicians receive the formal papers by certified mail, they can either surrender their licenses within 15 days or fight to keep them by requesting an administrative hearing--a step that could delay any license action by several months, he said.

On Monday, hospital officials stressed that the string of transfusion mishaps had nothing to do with laboratory procedure or the quality of employees hired at the hospital.

“They were isolated incidents in every case,” Alvarado spokesman Tom Berger said. “The state has looked at our procedures, and there has been no indication that these were anything more than unfortunate, isolated human errors.”

Hite also emphasized that state reviews showed that Alvarado’s guidelines for handling blood and nuclear medicine testing are sound.

Last month’s mix-up came during what Berger called a “common nuclear medicine procedure” whereby white blood cells are drawn from a patient, mixed with a “low-dose radioactive tracer,” and then injected back into the same patient so a special camera can watch them congregate at the point of an infection.

On Oct. 5, however, an unidentified Alvarado nuclear medicine technician injected the treated blood cells into the wrong patient. According to a copy of the state’s investigation into the mishap, the nuclear technician said he checked the patient’s identification wristband but “did not recognize the incorrect name.” He also admitted that he failed to check the physician’s orders in the patient’s medical records.

Although the nuclear technician promptly alerted hospital officials and, through them, the state about the mishap, Hite said the department felt it was proper to seek revocation of his license.

“We think that any situation where a patient’s life is at risk in a medical institution is not acceptable,” she said.

Citing patient confidentiality, Berger declined to say whether the patient suffered any ill effects from the botched procedure. But he and Maureen Malone, the hospital’s associate administrator, said the HIV virus was not transmitted.

Berger also refused to identify the nuclear technician; to say what, if any, disciplinary action the hospital took against him, or whether he continues to perform the procedure.

Berger said the hospital didn’t know the state would seek his license until it was contacted by The Times on Monday.