A Deadly Mistake in a Troubled Hospital : HIV-contaminated transfusion underscores the need for reforms at King / Drew

There is no excuse for an HIV-tainted blood transfusion to take place at a major hospital. Yet, tragically, that’s exactly what happened last year at the county’s troubled Martin Luther King Jr. / Drew Medical Center. Aleta Clemons, who went in for a hysterectomy, came out with the AIDS virus. Such a deadly mistake is unforgivable.

What can account for the failure to adhere to some of the most basic safety requirements? Where was the oversight? Missing in action-- again-- at the beleaguered public hospital.

Before the transfusion, the blood had already been determined to be HIV-positive and had been set aside for quarantine. Somehow Clemons received the contaminated blood.

Accidental transfusions of tainted blood were common 10 years ago, before the U.S. Food and Drug Administration took strong steps to safeguard the nation’s blood supply. Eventually, the accidents almost disappeared.

In the King / Drew case, federal and county investigators have blamed human error and criticized the hospital’s blood bank for a number of problems,including poor management, inadequate training, overwork, understaffing and staff bickering and other failures in communication. Investigators also determined that hospital officials had ignored written warnings from a blood bank supervisor that the transfusion service was understaffed and operating “in the Dark Ages.” In addition, the American Assn. of Blood Banks, which reviews blood bank operations, reported deficiencies that went uncorrected.

Los Angeles County supervisors are outraged at this tragedy, the latest of a string of failings at King / Drew. Clearly, the county must hold King management accountable and change the institutional culture that allowed this mistake. The nurse who accidentally released the blood has been allowed to resign. Several others have lost pay, been suspended or demoted. Stronger punishments would increase accountability throughout the hospital.

The patient who received the tainted blood in 1994 was not the only one who got blood that had tested positive for HIV. Luckily for the other person, the blood received turned out to not contain HIV; the test had been a “false positive.”

Clemons, who is already showing symptoms of AIDS, has sued the county for $1.5 million. Obviously the county--and that means the taxpayer--owes her. King/Drew has been the subject of numerous investigations over health and patient safety issues. Aleta Clemons’ horrible case is one that came to public attention through a Times article. What else is going on at public hospitals that county taxpayers don’t know about?