Due to medical errors, three patients died in three Houston hospitals in a short period of time. Each adverse event led to inspections by the federal Centers for Medicare and Medicaid Services (CMS) and sanctions as tough as revocation of deemed status for participation in the Medicare program.
That these events came so closely together, at three prominent hospitals in the same city, is part of the unusual story you will read. Significantly for our clients and readers, each hospital’s clinical laboratory is reported to have had a role in the errors that caused the deaths of the three patients. In two cases, errors in how patients were transfused were the cause of death. In the third case, “an ineffective process in patient monitoring and communication of critical lab values” contributed to the death of a patient being treated in an emergency room.
Houston newspapers and television news programs have run headline stories about the deaths of these three patients at Baylor St. Luke’s Medical Center, University of Texas MD Anderson Cancer Center, and Ben Taub Hospital. The news stories described the serious deficiencies identified during inspections by CMS and state officials.
Each of the three hospital laboratories had a role in the unfortunate deaths of the three patients, as described in CMS inspection reports. For this reason, clinical pathologists who are medical directors on the CLIA license of the labs they oversee should want to review these reports. The information can help them spot work practices in their own labs that could contribute to errors that cause severe patient harm.
Clinical pathologists will also want to follow how the three hospitals take corrective action to address the deficiencies identified by CMS—particularly those deficiencies that directly contributed to the deaths of the three patients. THE DARK REPORT has learned that one institution has already changed its pathology chair following recognition of the lab’s role in the death of the patient at its hospital. Other changes in lab directorships and lab managers may result at the three hospitals.
Every pathologist, medical technologist, and laboratory scientist knows the potential for even a minor error in the lab to negatively affect a patient. It is a testament to their skills that such errors do not happen often.